JFK Johnson Rehabilitation Institute
08/12/98 1
JFK Johnson Rehabilitation Institute
THE JFK COMA RECOVERY SCALE- REVISED:
CLINICAL AND RESEARCH APPLICATIONS
Joseph T. Giacino, Ph.D.
JFK Medical CenterJFK Johnson Rehabilitation Institute
andNJ Neuroscience Institute
Edison, NJ
JFK Johnson Rehabilitation Institute
Acknowledgements
• John Whyte, MD, Ph.D., Maddie DiPasquale, Ph.D., Monica Vaccaro, MA (MRRI)
• Nancy Childs, MD, Walt Mercer, Ph.D (Texas Rehab)
• Doug Katz, MD (Braintree HealthSouth Rehab)
• David Long, MD, Barbara Journey-Merges (Bryn Mawr)
• Stuart Yablon, MD, Mark Sherer, PhD (Methodist Rehab)
• Paul Novak, MA (Sunnyview Rehab)
• Bernd Eifert, MD, Petra Maurer, MA (FKNE)
JFK Johnson Rehabilitation Institute
COMBI Website Address
http://www.tbims.org/combi/crs/index.html
JFK Johnson Rehabilitation Institute
Purpose of CRS-R
• Determine diagnosis based on existing criteria• Promote inter-rater reliability• Establish prognosis• Project disposition needs• Monitor rate of recovery • Facilitate multidisciplinary treatment planning• Evaluate efficacy of treatment interventions• Alert to sub-clinical changes
JFK Johnson Rehabilitation Institute
JFK Coma Recovery Scale- Revised
(Giacino, et al Arch Phys Med
Rehabil, 2004.)
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CRS-R Psychometric Characteristics
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CRS-R: Descriptive Characteristics
Scale Type: Ordinal
Target Population: Rancho Level II - V
Assessment Areas: Auditory (4) Oromotor/Verbal (3)Visual (5) Communication (2)Motor (6) Arousal (3)
Hierarchical: Lowest Item - Reflexive
Highest Item - Cognitively-Based
Adm.Time: 30 mins
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CRS-R: Standardization Sample
N : 80 (48 M; 32 F)
Age Range: 17-79 (mean = 39)
Time Post Injury: 21-249 days (mean = 58)
Etiology: 37 TBI25 Vascular17 Anoxia
1 Tumor
CRS-R Total Score: 1-23 (mean = 12)
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CRS-R Total Score: Reliability Studies (n=20)
Inter-rater(Different raters/Same day): rs = 0.84*
Test-retest(Same rater/Different day): rs = 0.94*
Cross correlation(Different raters/Different days) rs = 0.79*
p<0.001*
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CRS-R Subscales: Interrater Reliability (n=20)
Cohen’s p RaterSUBSCALES Kappa Value Agreement
Auditory 0.86 0.01* 95%Visual 0.58 0.03* 80%Motor 0.78 0.01* 90%Oromotor/Verbal 0.77 0.03* 95%Communication 0.88 0.00* 95%
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CRS-R Subscales: Test-Retest Reliability (n=20)
Cohen’s p RaterSUBSCALES Kappa Value Agreement
Auditory 0.63 0.00* 85%Visual 0.90 0.00* 95%Motor 1.00 0.00* 100%Oromotor/Verbal 0.23 0.17 70%Communication 0.89 0.00* 95%
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CRS-R Diagnosis: Interrater Agreement
VS MCS MCS+ Total
VS 4 1 0 5
MCS 1 11 1 13
MCS+ 0 1 1 2
Total 5 13 2 20
Rater A1
Rater B
p=0.03*
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JFK Johnson Rehabilitation Institute
CRS-R Diagnosis: Test-Retest Agreement
VS MCS MCS+ Total
VS 5 0 0 5
MCS 1 11 1 13
MCS+ 0 0 2 2
Total 6 11 3 20
Rater A2
Rater A1
p=0.004*
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CRS-R: Internal Consistency
Aud Visual Motor O/V Comm
Visual 0.70
Motor 0.60 0.60
Oromo 0.51 0.29 0.47
Comm 0.62 0.54 0.49 0.65
Arousal 0.50 0.43 0.31 0.44 0.63
Cronbach’s Alpha=0.83*
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CRS-R, CRS and DRS Data Distribution (Validity Studies: n=80)
0
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
CRS-R Total Score
Frequency
0
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
CRS Total Score
0
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
DRS Total Score
Frequency
CRS-R
CRS
DRS
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CRS-R: Concurrent Validity
CRS-R and CRS: rs = 0.97 p<0.00001*
CRS-R and DRS: rs = -0.90 p<0.00001*
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CRS-R and DRS: Frequency of Diagnostic Agreement
MCS VS Total
MCS 51 10 61
VS 0 19 19
Total 51 29 80
DRS
CRS-R
87% Agreement
Sensitivity = 1.00 (95% CL: .913-1.00)Specificity = .655 (95% CL: .457-.814)
(Sherer, unpublished data)JFK Johnson Rehabilitation Institute
CRS: Sensitivity/Specificity in Predicting Outcome on the DRS
High Change
Low Change
Favorable Unfavorable
(Sherer, unpublished data)
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French CRS-R Validation Study
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French CRS-R: Validity and Interrater Reliability
(Schnakers, et al, 2008)
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Conclusions
• The CRS-R meets accepted standards for measurement and evaluation tools designed for use in interdisciplinary medical rehabilitation.
• The scale can be administered reliably by trained examiners and produces reasonably stable scores over repeated assessments.
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Conclusions (cont.)
• Validity analyses support use of the scale as an index of neurobehavioral function, although individual subscale scores should be used cautiously until additional data become available.
• Diagnostic application of the CRS-R suggests that the scale is capable of discriminating patients in MCS from those in VS.
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General CRS-R Administration and Scoring Guidelines
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Baseline Observation
Arousal Facilitation Protocol
Brainstem Reflex Assessment
CRS-R: Pre-Assessment Protocol
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Baseline Observation
Purpose
• Determine level of arousal.
• Facilitate selection of appropriate commands.
• Help differentiate volitional from random/coincidental movement.
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Baseline Observation (continued)
• If patient is not adequately aroused, administer Arousal Facilitation Protocol.
• Conduct 1 minute baseline observation period.
• Observe:• Resting posture of the extremities.• Eye opening status.• Presence or absence of spontaneous visual fixation. or
tracking.• Type and frequency of spontaneous movement.
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Baseline Observation & Command-Following Protocol
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Arousal Facilitation Protocol
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Brain Stem Reflex Assessment
• Purpose• Determine level of brain dysfunction to assist with
prognosis
• Aid in explanation of findings obtained on CRS-R
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Assessment of Brain Stem Reflexes
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Auditory Function Subscale
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Visual Function Subscale
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Motor Function Subscale
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Oromotor/Verbal Function Subscale
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Communication Subscale
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Arousal Subscale
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Scoring Guidelines
• Adhere to scoring criteria for each item
• Responses scored as present/absent
• Score elicited responses only (spontaneous behavior can be noted but not scored unless otherwise indicated)
• Do not score responses that occur after a 10 second interval has elapsed.
• Score best response within each subscale
• If response equivocal, do not credit
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CRS-R Discontinuation Criteria
• CRS-R is usually discontinued when the following criteria are met on three consecutive examinations:• Consistent movement to command
• Functional Communication: Accurate and
• Attention
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CRS-R Research
• Differential diagnosis• Outcome• Relation to functional neuroimaging• Treatment efficacy
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Diagnostic sensitivity
0
10
20
30
40
50
60
70
GCS FOUR WHIM CRS-R
2432 36
45
(Schnakers et al, Ann Neurol, 2006; Schnakers et al, Brain Injury, 2008)
Specialized assessment scalesSpecialized assessment scales
MCS Diagnosis (n=77)MCS Diagnosis (n=77)
*
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Diagnostic sensitivity
(Schnakers et al, Brain Injury, 2008)
0
5
10
15
20
25
30
35
40
45
AF VF MF OF C
CRSCRS--R SubscalesR Subscales
MCS Diagnosis (n=77)MCS Diagnosis (n=77)
23
36
21
212
*
Auditory Visual Motor Oro-motor Communication
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Differential diagnosis: EMCS v. MCS
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Differential diagnosis: EMCS v. MCS
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Differential diagnosis
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Percentage of MCS patients showing visual pursuit by type of stimulus
Vanhaudenhuyse et al, JNNP, 2008
Num
ber o
f patients
Mirror
Person
Object
n = 38
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Outcome Studies
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Incidence of blink to threat in VS and relationship to outcome
Num
ber
of p
atie
nts
DiedVSEmerged VS
with blink (n=46) without blink (n=45)
p > .05
(Vanhaudenhuyse, Giacino, Schnakers, et al., Neurol, 2008)
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Forward Speech
BackwardSpeech
Comparison of behavioral and fMRI findings: Language
L R
(Manuscript in preparation)(Manuscript in preparation)
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Checkerboard
Comparison of behavioral and fMRI findings: Vision
Landscapes
L
Faces
L R
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Treatment Studies
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Treatment Studies
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Treatment Studies
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-309
-296
-283
-270
-257
-244
-231
-218
-205
-192
-179
-166
-153
-140
-127
-114
-101 -88
-75
-62
-49
-36
-23
-10 3
0
100
200
300
400
500
600
700
800
900
-309
-296
-283
-270
-257
-244
-231
-218
-205
-192
-179
-166
-153
-140
-127
-114
-101 -88
-75
-62
-49
-36
-23
-10
Cumulative Hours of Rehab/DBS Exposure
Days
Rehab
23
123
456
Surgery
Intelligible Words
-303 -253 -203 -153 -103 -53 -3
DBS ON
Vocalization Only
Sustained Attention
Eyes Open w/o Stim
Eyes Open w/ Stim
Functional Object Use
Object Manipulation
Automatic Movement
CRS-R Scores
DBS ONDBS OFF
O/V
Arousal
Motor
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Merci!
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