Abstract
The Nociception Coma Scale (NCS) and its revised version (NCS-R) were used to evaluate behavioral responses to pain in non-communicative patients. We hypothesized that if patients demonstrate changes to their NCS(-R) scores over time, their evolving behavioral abilities could indicate a forthcoming diagnostic improvement with the Coma Recovery Scale-Revised (CRS-R). Forty-three Vegetative State/Unresponsive Wakefulness Syndrome (VS/UWS) patients were enrolled in the study. The patients were assessed weekly using the CRS-R and NCS(-R) for four consecutive weeks. The first assessment was within 10 days after hospitalization. The assessments were performed between 09:30 and 11:30 AM in a room with constant levels of humidity, light and temperature, as well as an absence of transient noise. Noxious stimuli were administered using a Newton-meter, with pressure applied to the fingernail bed for a maximum of 5 s unless interrupted by a behavioral response from subjects. Seventeen patients demonstrated improvements in their level of consciousness, 13 of whom showed significant behavioral changes through the NCS(-R) before being diagnosed with a Minimally Conscious State (MCS) according to the CRS-R. The behavioral changes observed using the NCS(-R) corresponded to a high probability of observing an improvement from VS/UWS to MCS. To characterize the increased likelihood of this transition, our results present threshold scores of ≥5 for the NCS (accuracy 86%, sensitivity 87%, and specificity 86%) and ≥3 for the NCS-R (accuracy 77%, sensitivity 89%, and specificity 73%). In conclusion, a careful evaluation of responses to nociceptive stimuli in DOC patients could constitute an effective procedure in assessing their evolving conscious state.
Highlights
Patients were excluded from the study for the following: (i) documented history of prior brain injury; (ii) premorbid history of developmental, psychiatric or neurologic illness resulting in documented functional disability up to the time of the injury; (iii) neurological or psychiatric disease history; (iv) upper limb contusions, fractures, or flaccid paralysis; (v) mechanical ventilation; (vi) clinical instability, including treatment with neuroactive drugs, and concurrent systemic disorders, or evidence of recurrent pain as assessed by clinicians; (vii) a transition out of Vegetative State/Unresponsive Wakefulness Syndrome (VS/UWS) diagnosis within weeks of the first Coma Recovery Scale-Revised (CRS-R) and Nociception Coma Scale (NCS)(-R) assessments
Significant differences were found between the VS/UWS◦
Apart from evaluating conscious characteristics, its administration was recommended because patients may already experience pain as a result of conditions related to their circumstances
Summary
We hypothesized that by observing gradual changes in the NCS(-R) total scores of patients, there may be an identifiable threshold score that indicates a higher probability of improved outcomes for patients, and to the patients in our study, a transition from a VS/UWS to a MCS diagnosis. In the VS/UWS condition, there is no behavioral evidence of self or environmental awareness. Behavioral sleep/wake cycles and arousal are preserved (Multi-Society Task Force on PVS, 1994). MCS patients show some signs of awareness, such as visual pursuit, localization to pain, or non-systematic command-following, though they are unable to communicate their thoughts or feelings (Giacino and Kalmar, 2005; Giacino and Smart, 2007)
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