JFK Johnson Rehabilitation Institute · MCS Diagnosis (n=77) * JFK Johnson Rehabilitation Institute Diagnostic sensitivity (Schnakers et al, Brain Injury, 2008) 0 5 10 15 20 25 30

JFK Johnson Rehabilitation Institute

08/12/98 1


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


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)


COMBI Website Address

http://www.tbims.org/combi/crs/index.html


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 Coma Recovery Scale- Revised

(Giacino, et al Arch Phys Med

Rehabil, 2004.)


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


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)


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*


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%


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%


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*


08/12/98 3


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*


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*


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


CRS-R: Concurrent Validity

CRS-R and CRS: rs = 0.97 p<0.00001*

CRS-R and DRS: rs = -0.90 p<0.00001*


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)


08/12/98 4


French CRS-R Validation Study


French CRS-R: Validity and Interrater Reliability

(Schnakers, et al, 2008)


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.


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.


General CRS-R Administration and Scoring Guidelines


Baseline Observation

Arousal Facilitation Protocol

Brainstem Reflex Assessment

CRS-R: Pre-Assessment Protocol


08/12/98 5


Baseline Observation

Purpose

• Determine level of arousal.

• Facilitate selection of appropriate commands.

• Help differentiate volitional from random/coincidental movement.


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.


Baseline Observation & Command-Following Protocol


Arousal Facilitation Protocol


Brain Stem Reflex Assessment

• Purpose• Determine level of brain dysfunction to assist with

prognosis

• Aid in explanation of findings obtained on CRS-R


Assessment of Brain Stem Reflexes


08/12/98 6


Auditory Function Subscale


Visual Function Subscale


Motor Function Subscale


Oromotor/Verbal Function Subscale


Communication Subscale


Arousal Subscale


08/12/98 7


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


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


CRS-R Research

• Differential diagnosis• Outcome• Relation to functional neuroimaging• Treatment efficacy


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)

*


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


Differential diagnosis: EMCS v. MCS


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Differential diagnosis: EMCS v. MCS


Differential diagnosis


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


Outcome Studies


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)


Forward Speech

BackwardSpeech

Comparison of behavioral and fMRI findings: Language

L R

(Manuscript in preparation)(Manuscript in preparation)


08/12/98 9


Checkerboard

Comparison of behavioral and fMRI findings: Vision

Landscapes

L

Faces

L R


Treatment Studies


Treatment Studies


Treatment Studies


-309

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-231

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-192

-179

-166

-153

-140

-127

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-101 -88

-75

-62

-49

-36

-23

-10 3

0

100

200

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400

500

600

700

800

900

-309

-296

-283

-270

-257

-244

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-192

-179

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-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


Merci!

Documents

JFK Johnson Rehabilitation Institute · MCS Diagnosis (n=77) * JFK Johnson Rehabilitation Institute Diagnostic sensitivity (Schnakers et al, Brain Injury, 2008) 0 5 10 15 20 25 30