Original research| Volume 99, ISSUE 5, P914-919, May 2018

Improvement on the Coma Recovery Scale–Revised During the First Four Weeks of Hospital Stay Predicts Outcome at Discharge in Intensive Rehabilitation After Severe Brain Injury

Published:February 08, 2018DOI:



      To evaluate the prognostic utility of serial assessment on the Coma Recovery Scale–Revised (CRS-R) during the first 4 weeks of intensive rehabilitation in patients surviving a severe brain injury.


      Prospective cohort study.


      An intensive rehabilitation unit.


      Patients (N=110) consecutively admitted to the intensive rehabilitation unit. Inclusion criteria were (1) a diagnosis of unresponsive wakefulness syndrome (UWS) or minimally conscious state (MCS) caused by an acquired brain injury, and (2) aged >18 years.


      All patients underwent clinical evaluations using the Italian version of the CRS-R during the first month of hospital stay.

      Main Outcome Measures

      Behavioral classification on the CRS-R and the score on the Glasgow Outcome Scale (GOS) at final discharge. Patients transitioning from UWS to MCS or emergence from MCS (E-MCS), and from MCS to E-MCS were classified as patients with improved responsiveness (IR).


      After a mean ± SD hospital stay of 5.3±2.7 months, 59 of 110 patients (53.6%) achieved IR. In the multivariable analysis, a higher CRS-R score change at week 4 (odds ratio =1.99; 95% confidence interval [CI], 1.49–2.66; P<.001) was the only significant predictor of IR at discharge. Fifty-three patients (48.2%) were classified as severely impaired at discharge (GOS=3). In the multivariable analysis, higher GOS scores were related to a higher CRS-R score at admission (B=.051; 95% CI, .027–.074; P<.001), a higher CRS-R score change at week 4 (B=.087; 95% CI, .064–.110; P<.001), and an absence of severe infections (B=–.477; 95% CI, –.778 to –.176; P=.002).


      An improvement on the total CRS-R score and on different subscales across the first 4 weeks of inpatient rehabilitation discriminates patients who will have a better outcome at discharge, providing information for rehabilitation planning and for communication with patients and their caregivers.


      List of abbreviations:

      CI (confidence interval), CRS-R (Coma Recovery Scale–Revised), E-MCS (emergence from minimally conscious state), GOS (Glasgow Outcome Scale), IR (improved responsiveness), MCS (minimally conscious state), UWS (unresponsive wakefulness syndrome)
      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


        • Childs N.L.
        • Mercer W.N.
        • Childs H.W.
        Accuracy of diagnosis of persistent vegetative state.
        Neurology. 1993; 43: 1465-1467
        • 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
        • 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
        • 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
        • Løvstad M.
        • Frøslie K.F.
        • Giacino J.T.
        • Skandsen T.
        • Anke A.
        • Schanke A.K.
        Reliability and diagnostic characteristics of the JFK Coma Recovery Scale-Revised: exploring the influence of rater's level of experience.
        J Head Trauma Rehabil. 2010; 25: 349-356
        • McDonnell E.
        • Giacino J.T.
        • Kolakowsky-Hayner S.A.
        A brief overview of the Coma Recovery Scale-Revised: updates from the COMBI.
        J Head Trauma Rehabil. 2015; 30: 143-145
        • Hirschberg R.
        • Giacino J.T.
        The vegetative and minimally conscious states: diagnosis, prognosis and treatment.
        Neurol Clin. 2011; 29: 773-786
        • Multi-Society Task Force on PVS
        Medical aspects of the persistent vegetative state (2).
        N Engl J Med. 1994; 330: 1572-1579
        • Giacino J.T.
        • Kalmar K.
        Diagnostic and prognostic guidelines for the vegetative and minimally conscious states.
        Neuropsychol Rehabil. 2005; 15: 166-174
        • 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
        • 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
        • 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
        • Eapen B.C.
        • Allred D.B.
        • O'Rourke J.
        • Cifu D.X.
        Rehabilitation of moderate-to-severe traumatic brain injury.
        Semin Neurol. 2015; 35: e1-e3
        • Bernat J.L.
        Chronic disorders of consciousness.
        Lancet. 2006; 367: 1181-1192
        • Giacino J.T.
        • Ashwal S.
        • Childs N.
        • et al.
        The minimally conscious state: definition and diagnostic criteria.
        Neurology. 2002; 58: 349-353
        • Lombardi F.
        • Gatta G.
        • Sacco S.
        • Muratori A.
        • Carolei A.
        The Italian version of the Coma Recovery Scale-Revised (CRS-R).
        Funct Neurol. 2007; 22: 47-61
        • Estraneo A.
        • Moretta P.
        • De Tanti A.
        • et al.
        An Italian multicentre validation study of the Coma Recovery Scale-Revised.
        Eur J Phys Rehabil Med. 2015; 51: 627-634
        • Jennett B.
        • Bond M.
        Assessment of outcome after severe brain damage.
        Lancet. 1975; 1: 480-484
        • McMillan T.
        • Wilson L.
        • Ponsford J.
        • Levin H.
        • Teasdale G.
        • Bond M.
        The Glasgow Outcome Scale—40 years of application and refinement.
        Nat Rev Neurol. 2016; 12: 477-485
        • Sacco S.
        • Altobelli E.
        • Pistarini C.
        • Cerone D.
        • Cazzulani B.
        • Carolei A.
        Validation of the Italian version of the Coma Recovery Scale-Revised (CRS-R).
        Brain Inj. 2011; 25: 488-495
        • Noé E.
        • Olaya J.
        • Navarro M.D.
        • et al.
        Behavioral recovery in disorders of consciousness: a prospective study with the Spanish version of the Coma Recovery Scale-Revised.
        Arch Phys Med Rehabil. 2012; 93: 428-433.e12
        • Estraneo A.
        • Moretta P.
        • Loreto V.
        • et al.
        Predictors of recovery of responsiveness in prolonged anoxic vegetative state.
        Neurology. 2013; 80: 464-470
        • 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
        • Estraneo A.
        • Moretta P.
        • Cardinale V.
        • et al.
        A multicentre study of intentional behavioural responses measured using the Coma Recovery Scale-Revised in patients with minimally conscious state.
        Clin Rehabil. 2015; 29: 803-808
        • Bagnato S.
        • Boccagni C.
        • Sant'Angelo A.
        • Fingelkurts A.A.
        • Galardi G.
        Longitudinal assessment of clinical signs of recovery in patients with unresponsive wakefulness syndrome after traumatic or nontraumatic brain injury.
        J Neurotrauma. 2017; 34: 535-539
        • Pignat J.M.
        • Mauron E.
        • Jöhr J.
        • et al.
        Outcome prediction of consciousness disorders in the acute stage based on a complementary motor behavioural tool.
        PLoS One. 2016; 11: e0156882
      1. Consensus conference. Rehabilitation of persons with traumatic brain injury. NIH Consensus Development Panel on Rehabilitation of Persons With Traumatic Brain Injury.
        JAMA. 1999; 282: 974-983
        • Holland D.
        • Shigaki C.L.
        Educating families and caretakers of traumatically brain injured patients in the new health care environment: a three phase model and bibliography.
        Brain Inj. 1998; 12: 993-1009
        • Junqué C.
        • Bruna O.
        • Mataró M.
        Information needs of the traumatic brain injury patient's family members regarding the consequences of the injury and associated perception of physical, cognitive, emotional and quality of life changes.
        Brain Inj. 1997; 11: 251-258
        • Lefebvre H.
        • Levert M.J.
        Breaking the news of traumatic brain injury and incapacities.
        Brain Inj. 2006; 20: 711-718
        • Wijdicks E.F.
        • Hijdra A.
        • Young G.B.
        • Bassetti C.L.
        • Wiebe S.
        Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter: prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology.
        Neurology. 2006; 67: 203-210
        • 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
        • Amantini A.
        • Carrai R.
        • Fossi S.
        • Pinto F.
        • Grippo A.
        The role of early electroclinical assessment in improving the evaluation of patients with disorders of consciousness.
        Funct Neurol. 2011; 26: 7-14
        • Grippo A.
        • Carrai R.
        • Scarpino M.
        • et al.
        Neurophysiological prediction of neurological good and poor outcome in post-anoxic coma.
        Acta Neurol Scand. 2017; 135: 641-648