Article

OBJECTIVES: To conduct a systematic review of behavioral assessment scales for
disorders of consciousness (DOC); provide evidence-based recommendations for
clinical use based on their content validity, reliability, diagnostic validity,
and ability to predict functional outcomes; and provide research recommendations
on DOC scale development and validation. DATA SOURCES: Articles published through
March 31, 2009, using MEDLINE, CINAHL, Psychology and Behavioral Sciences
Collection, Cochrane Database of Systematic Reviews, Database of Abstracts of
Reviews of Effects, Cochrane Central Register of Controlled Trials, Biomedical
Reference Collection, and PsycINFO. Thirteen primary terms that defined DOC were
paired with 30 secondary terms that defined aspects of measurement. Scale names,
abbreviations, and authors were also used as search terms. Task force members
identified additional articles by using personal knowledge and examination of
references in reviewed articles. STUDY SELECTION: Primary criteria included the
following: (1) provided reliability, diagnostic validity, and/or prognostic
validity data; (2) examined a cohort, case control, or case series sample of
persons with DOC who were age older than or equal to 18 years; and (3) assessed
in an acute care or rehabilitation setting. Articles were excluded if peer review
was not conducted, original data were not reported, or an English language
article was not available. The initial search yielded 580 articles. After paired
rater review of study abstracts, guideline development was based on 37 articles
representing 13 DOC scales. DATA EXTRACTION:
Rater pairs classified studies
addressing diagnostic and prognostic validity by using the American Academy of
Neurology 4-tier level of evidence scheme, and reliability by using a task
force-developed 3-tier evidence scheme. An independent quality review of ratings
was conducted, and corrections were made. DATA SYNTHESIS: The Coma Recovery
Scale-Revised (CRS-R), Sensory Stimulation Assessment Measure (SSAM), Wessex Head
Injury Matrix (WHIM), Western Neuro Sensory Stimulation Profile (WNSSP), Sensory
Modality Assessment Technique (SMART), Disorders of Consciousness Scale (DOCS),
and Coma/Near-Coma Scale (CNC) have acceptable standardized administration and
scoring procedures. The CRS-R has excellent content validity and is the only
scale to address all Aspen Workgroup criteria. The SMART, SSAM, WHIM, and WNSSP
demonstrate good content validity, containing items that could distinguish
persons who are in a vegetative state, are in a minimally conscious state (MCS),
or have emerged from MCS. The Full Outline of UnResponsiveness Score (FOUR),
WNSSP, CRS-R, Comprehensive Levels of Consciousness Scale (CLOCS), and Innsbruck
Coma Scale (INNS) showed substantial evidence of internal consistency. The FOUR
and the CRS-R showed substantial evidence of good interrater reliability.
Evidence of diagnostic validity and prognostic validity in brain injury survivor
samples had very high levels of potential bias because of methodologic issues
such as lack of rater masking. CONCLUSIONS: The CRS-R may be used to assess DOC
with minor reservations, and the SMART, WNSSP, SSAM, WHIM, and DOCS may be used
to assess DOC with moderate reservations. The CNC may be used to assess DOC with
major reservations. The FOUR, INNS, Glasgow-Liege Coma Scale, Swedish Reaction
Level Scale-1985, Loewenstein Communication Scale, and CLOCS are not recommended
at this time for bedside behavioral assessment of DOC because of a lack of
content validity, lack of standardization, and/or unproven reliability.
CI - Copyright (c) 2010 American Congress of Rehabilitation Medicine. Published by
Elsevier Inc. All rights reserved.

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