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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:https://doi.org/10.1016/j.apmr.2018.01.015

      Abstract

      Objectives

      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.

      Design

      Prospective cohort study.

      Setting

      An intensive rehabilitation unit.

      Participants

      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.

      Interventions

      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).

      Results

      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).

      Conclusions

      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.

      Keywords

      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)
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