Disorders Of Consciousness Scale Research Articles

Evaluation of the effectiveness of transcranial direct current stimulation (tDCS) and psychosensory stimulation through DOCS scale in a minimally conscious subject

ABSTRACTThe aim of our study was to assess the effectiveness of transcranial direct current stimulation (tDCS) on alertness improvement in a patient in a minimally conscious state (MCS) by means of disorders of consciousness scale combined with psycho-sensory stimulation. The effects of tDCS on muscle hypertonia through the Ashworth scale were also examined. tDCS was performed through a two-channel intra-cephalic stimulator. After stimulation, the patient followed a psychosensory stimulation training. Results pointed out an increase in DOCunit score, as well as an increase in alertness maintenance and an improvement in muscle hypertonia, although a MCS state persisted.

Placebo-Controlled Trial of Familiar Auditory Sensory Training for Acute Severe Traumatic Brain Injury

Background. Sensory stimulation is often provided to persons incurring severe traumatic brain injury (TBI), but therapeutic effects are unclear. Objective. This preliminary study investigated neurobehavioral and neurophysiological effects related to sensory stimulation on global neurobehavioral functioning, arousal, and awareness. Methods. A double-blind randomized placebo-controlled trial where 15 participants in states of disordered consciousness (DOC), an average of 70 days after TBI, were provided either the Familiar Auditory Sensory Training (FAST) or Placebo of silence. Global neurobehavioral functioning was measured with the Disorders of Consciousness Scale (DOCS). Arousal and awareness were measured with the Coma-Near-Coma (CNC) scale. Neurophysiological effect was measured using functional magnetic resonance imaging (fMRI). Results. FAST (n = 8) and Placebo (n = 7) groups each showed neurobehavioral improvement. Mean DOCS change (FAST = 13.5, SD = 8.2; Placebo = 18.9, SD = 15.6) was not different, but FAST patients had significantly (P = .049; 95% confidence interval [CI] = −1.51, −.005) more CNC gains (FAST = 1.01, SD = 0.60; Placebo = 0.25, SD = 0.70). Mixed-effects models confirm CNC findings (P = .002). Treatment effect, based on CNC, is large (d = 1.88, 95% CI = 0.77, 3.00). Number needed to treat is 2. FAST patients had more fMRI activation in language regions and whole brain (P values <.05) resembling healthy controls’ activation. Conclusions. For persons with DOC 29 to 170 days after TBI, FAST resulted in CNC gains and increased neural responsivity to vocal stimuli in language regions. Clinicians should consider providing the FAST to support patient engagement in neurorehabilitation.

Psychometric Properties of the Disorders of Consciousness Scale

ObjectiveTo provide evidence for psychometric properties of the Disorders of Consciousness Scale (DOCS). DesignProspective observational cohort. SettingsSeven rehabilitation facilities. ParticipantsPatients (N=174) with severe brain injury. InterventionsNot applicable. Main Outcome MeasureDOCS. ResultsInitial analyses suggested eliminating 6 items to maximize psychometrics, resulting in the DOCS-25. The 25 items form a unidimensional hierarchy, rating scale categories are ordered, there are no misfitting items, and differential item functioning was not found according to sex, type of brain injury, veteran status, and days from onset. Person separation reliability (.91) indicates that the DOCS-25 is appropriate for individual patient measurement. Items are well targeted to the sample, with the difference between mean person and item calibrations less than 1 logit. DOCS-25 Rasch measures result in a 62% gain in relative precision over total raw scores. Internal consistency is very good (Cronbach α=.86); interrater agreement is excellent (intracIass correlation coefficient=.90) for both the DOCS-25 and the sensory subscales. The DOCS-25 total measure, but not subscale measures, correlates with the Glasgow Coma Scale and the Coma/Near-Coma Scales and distinguishes significantly between vegetative and minimally conscious states, indicating concurrent validity. ConclusionsThe DOCS-25 is psychometrically strong. It has excellent measurement precision and captures a broad range of patient function, which is critical for capturing recovery of consciousness. The sensory subscales are clinically informative but should not be reported as separate measures. The Keyform synthesizes clinical observations to visualize response patterns with potential for informing clinical decision-making. Future studies should determine sensitivity to change, examine issues of rater severity, and explore the usefulness of the Keyform in clinical practice.

DOCS Keyform: Clinically Meaningful Tracking of Neurobehavioral Function in Patients with Severe Traumatic Brain Injury

1)To describe the structure, development, and purpose of Keyforms.2)To describe the development of a Keyform using the Disorders of Consciousness Scale (DOCS) in civilian and veterans with severe traumatic brain injury (TBI).3)To demonstrate how the DOCS Keyform can be used to track recovery of neurobehavioral function in 3 case examples with severe TBI. Secondary analysis of repeated measures of the DOCS, a reliable and valid, clinician-observed measure of neurobehavioral function (NBF). Inpatient rehabilitation facilities. 174 civilians and veterans with severe TBI. N/A. DOCS. Patients were evaluated weekly for up to six weeks. 25 DOCS reflect 4 sensory modalities: gustation/olfaction, auditory language, visual, and somatosensory. Data were analyzed using Rasch Analysis applying a partial credit model and adjusting for rater severity/leniency. Items of the DOCs were calibrated to form a hierarchy of NBF. These item calibrations were used to develop the DOCS Keyform, a 2-dimensional, graphical display that reflects the recovery of consciousness and enables simultaneous scoring and measurement of NBF. This is demonstrated in 3 case examples. The DOCS Keyform provides a simple and accurate way to monitor clinical change in NBF and indicate in which sensory modalities recovery is occurring. The DOCS Keyform allows clinicians to target appropriate goals for each modality based on the patients current NBF in each modality and aids communication with family members.

Predicting levels of independence with expressing needs and ideas 1 year after severe brain injury.

Severe brain injury (BI) is a catastrophic event often evolving into a complex chronic and severely disabling condition making activity participation possible only with sustained caregiving. One aspect of building sustainable caregiving is early provision of information about expected outcomes germane to patients and their caregivers. An analysis was conducted to determine whether 2 levels of independence with expressing needs and ideas 1-year after severe BI could be predicted using variables available early after injury. The authors examined a subsample (n = 79) of participants of an outcome study who received repeated neurobehavioral evaluations with the Disorders of Consciousness Scale (DOCS) and who were assessed 1 year after injury with the Functional Independence Measures (FIM). Explanatory variables included DOCS measures, patient characteristics, coexisting conditions, and interventions. The outcome is measured with the FIM Expression item. Optimal data analysis was used to construct multivariate classification tree models. The 2nd (p = .004) DOCS visual measure and seizure (p = .004) entered the final model providing 79% accuracy in classifying more or less independence with expressing needs and ideas at 1 year. The model will correctly identify 78% of future severe BI survivors who will have more independence and 82% of persons who will have less independence. For persons incurring severe BI, it is possible to predict, early after injury, more and less independence with expressing needs and ideas 1-year after injury. This evidence is 1 contribution to a larger body of evidence needed to enable early caregiver education about recovery expectations in terms of patient functioning relative to caregiving needs, which in turn will help build sustainable caregiving for this population.

Responsiveness of Instruments to Assess Disorders of Consciousness: A Literature Review

Objectives: To summarise available evidence for responsiveness of six key assessments used with patients with disorders of consciousness: Coma Recovery Scale – Revised (CRS-R), Disorders Of Consciousness Scale (DOCS), Sensory Modality Assessment and Rehabilitation Technique (SMART), Sensory Stimulation Assessment Measure (SSAM), Wessex Head Injury Matrix (WHIM), and the Western Neuro Sensory Stimulation Profile (WNSSP).Method: A literature search of five electronic databases was conducted using a systematic search strategy. Relevant literature was evaluated and pertinent information extracted.Results: Database searches using key terms initially yielded 132 articles. Following review for inclusion identified 24 articles. No studies were specifically designed to investigate responsiveness of any of the measures and therefore responsiveness data were either based on statistical significance of change post-treatment or descriptive analysis of change scores. The majority of studies identified used the CRS-R (n= 11), WHIM (n= 5) and WNSSP (n= 6) and have established responsiveness to change. There is some preliminary evidence for the responsiveness of the other measures, based on very few available studies: DOCS (n= 2), SMART (n= 1) or SSAM (n= 1).Conclusion: Future studies should seek to include responsiveness analysis, particularly in relation to the DOCS, SMART and SSAM.

Poster 1 Safety and Efficacy of Repetitive Transcranial Magnetic Stimulation (rTMS) for Two Persons in Vegetative State

Demonstrate safety and efficacy of repetitive transcranial magnetic stimulation (rTMS) for severe traumatic brain injury (TBI). Baseline-Control Pilot. Medical research unit. Two men in vegetative state for 287 and 188 days. Poor recovery likelihood indicated by low odds (27% ; 45%) for regaining consciousness and unresponsiveness to somatosensory evoked potentials (SSEP). rTMS subjects are compared with controls (n = 22) admitted to rehabilitation an average of 54 days after TBI. 30 rTMS sessions without neurostimulants. For both groups, neurobehavioral functioning measured for six weeks with the Disorders of Consciousness Scale (DOCS). For rTMS, functional imaging, diffusion tensor imaging (DTI), functional connectivity, brainstem auditory evoked potentials, SSEP and safety data collected at least weekly. No adverse events. rTMS # 1 progressed from non-responsive to inconsistent command following and answering yes/no questions (DOCS gain = 15.2). rTMS # 2 progressed from non-responsive to consistent communication in sentences (DOCS gain= 9.7). rTMS subjects achieved greater DOCS gains than average control gains (9.2). Region of interest, functional connectivity and DTI findings indicate that rTMS neurobeahvioral gains related to increasing number and strength of significantly (p = 0.001) correlated regions and between the Brainstem, Thalamus, Wernicke's and Heschl's. Patterns corresponding with more function (#2), relative to less (#1), include increasing strength of some correlations simultaneous with decreasing strength of others s (e. g. midbrain to thalamus) and bilateral rather than only ipsilateral changes. DOCS gains during rTMS exceed controls' gains and correspond with changes in brainstem-thalamo-cortical connections.

Poster 94: Predictive Value of the Disorders of Consciousness Scale: Overall Neurobehavioral Change and Change by Modalities

Objectives: To examine the predictive validity of neurobehavioral change derived from the Disorders of Consciousness Scale (DOCS). Design: Prospective observational predictive validity study. Setting: Inpatient rehabilitation hospitals and postrehabilitation residence. Participants: 113 persons with a mean age of 38±17.8 who were unconscious for >28 days consecutively after severe BI; 73% (83/113) with traumatic BI and 27% (30/113) with other BI. Interventions: Not applicable. Main Outcome Measures: The measures derived from the DOCS reflect changes in overall neurobehavioral functioning and changes in functioning according to modalities. The outcomes include return to consciousness 4, 8 and 12 months after severe brain injury (BI). Results: When controlling for injury type, the DOCS average as well as DOCS change between the first and second DOCS (DOCS1-2), first and fifth DOCS (DOCS1-5) and first and last DOCS (DOCStotalchg) significantly (P ≤.05) contributed to predicting recovery and lack of recovery of consciousness at 4, 8 and/or 12 months after injury. DOCS1-5 manifested the most balanced accuracy in predictions where predicting recovery of consciousness is accurate 87% of the time and predicting lack of recovery of consciousness is accurate 88% of the time. Modality measures derived from the DOCS being examined, at time of writing this abstract, include sensory, partial cognitive, higher cognitive, auditory, tactile and visual measures. Conclusions: For persons with prolonged disorders of consciousness, the findings indicate that evidence based prognostication for individual patients are possible. Modality measures may enhance accuracy. The implications for research are that the DOCS can be used as a meaningful, reliable and valid primary outcome to measure treatment effects in clinical trials. The evidence indicates further that DOCS measures merit inclusion in future research aiming to develop multivariate prognostication models.

Predictive Value of the Disorders of Consciousness Scale (DOCS)

To examine the predictive validity of measures of neurobehavioral change derived from the Disorders of Consciousness Scale (DOCS) for predicting return to consciousness 4, 8, and 12 months after severe brain injury (BI). Prospective observational predictive validity study Inpatient rehabilitation hospitals and postrehabilitation residence A total of 113 persons with a mean age of 38 +/- 17.8 years who were unconscious for >28 days consecutively after severe BI; 73% (83/113) with traumatic BI and 27% (30/113) with other BI. Baseline DOCS, DOCS average, change from baseline DOCS to subsequent DOCS (DOCS2, DOCS3, DOCS4, DOCS5, DOCS6), and injury type (traumatic BI vs. other BI) MAIN OUTCOME MEASURE: Time to consciousness at 4, 8, and 12 months after injury When controlling for injury type, the DOCS average as well as DOCS change between the first and second DOCS (DOCS1-2), first and fifth DOCS (DOCS1-5) and first and last DOCS (DOCStotalchg) significantly (P < or = .05) contributed to predicting recovery and lack of recovery of consciousness at 4, 8, and/or 12 months after injury. DOCS1-5 manifested the most balanced accuracy in predictions, where predicting recovery of consciousness is accurate 87% of the time and predicting lack of recovery of consciousness is accurate 88% of the time. For persons with prolonged disorders of consciousness, the findings indicate that evidence-based prognostication for individual patients is possible. The implications for research are that the DOCS can be used as a meaningful, reliable, and valid primary outcome to measure treatment effects in clinical trials. The evidence indicates further that DOCS measures merit inclusion in future research that aims to develop multivariate prognostication models.

Poster 30: Management, Outcomes, and Prognostication During Coma Recovery

Objective: To illustrate the predictive utility of the Disorders of Consciousness Scale (DOCS) change score and medical variables available early after injury by comparing predicted and actual outcomes. Design: Prospective observational study. Setting: Inpatient rehabilitation. Participants: 64 participants unconscious after severe brain injury. Intervention: Weekly DOCS evaluations until inpatient rehabilitation discharge. After inpatient discharge, monthly follow-up with final outcome interview 1 year after injury.

P.5.100 Peptidergic strategy of pharmacologicalcorrection of asthenic disorders

Report of the American Congress of Rehabilitation Medicine, Brain Injury-Interdisciplinary Special Interest Group, Disorders of Consciousness Task Force: Seel RT, Task Force Chair, Sherer M, Whyte J, Katz DI, Giacino JT, Rosenbaum AM, Hammond FM, Kalmar K, Pape TL, Zafonte R, Biester RC, Kaelin D, Kean J, Zasler N. Assessment scales for disorders of consciousness: evidence-based recommendations for clinical practice and research.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.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.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.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.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.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.

A measure of neurobehavioral functioning after coma. Part I: Theory, reliability, and validity of the Disorders of Consciousness Scale

This is longitudinal validation study describes the psychometric properties of the Disorders of Consciousness Scale (DOCS). This is Part I of a two-part series. Part II illustrates and describes the clinical and scientific implementation of the DOCS measure. The study was conducted at one intensive care unit, two acute rehabilitation hospitals, and one long-term acute chronic care hospital. Participants were unconscious after severe brain injury (BI). We conducted interrater reliability analyses using ratings from interdisciplinary pairs. Results indicated a higher-than-expected level of agreement and no significant difference between any pairs ( chi-square = 8(5df), p = 0.15) (df = degrees of freedom). Examinations of ratings by discipline groups indicated that the DOCS is impacted minimally by discipline. Validity analyses demonstrate that 23 of 34 test stimuli remain stable over time with no floor or ceiling effect. DOCS measures obtained within 94 days of injury predicted recovery of consciousness up to 1 year after injury (c-indices of 0.70 and 0.86). Positive (0.71) and negative (0.68) predictive values indicate that the DOCS predicts recovery and lack of recovery. Twenty-three of the DOCS test stimuli produce a reliable, valid, and stable measure of neurobehavioral recovery after severe BI that predicts recovery and lack of recovery of consciousness 1 year after injury.

A measure of neurobehavioral functioning after coma. Part II: Clinical and scientific implementation

This is a longitudinal validation study that is Part II of a two-part series. Part I focuses on the methods used to construct the neurobehavioral measure derived from the Disorders of Consciousness Scale (DOCS) as well as the evidence of reliability and validity. Part II illustrates, through a series of selected case reports, the clinical use of repeated DOCS measures to enhance and complement medical rehabilitation management. The use of repeated DOCS measures in scientific investigations of mechanisms of injury is also described. Participants included patients at rehabilitation hospitals who were 18 years of age and older and unconscious after severe brain injury. Medical decision making regarding short-term effects of pharmacological intervention was augmented and improved through the examination of individual neurobehavioral recovery patterns. We identified medications to treat secondary medical complications and successfully determined effective dosage, presumably improving prognosis for recovery. We facilitated and enhanced development and refinement of individualized rehabilitation programs. Two investigations of treatment effectiveness during coma recovery and examination of the relationship between behavioral changes and neural adaptation are also described. By systematically tracking and mapping individual patterns of neurobehavioral recovery, we show that medical and rehabilitation management after coma can be enhanced. In addition, we also show that by examining the relationship between the DOCS neurobehavioral measure with mechanistic indicators of neurological recovery such as functional magnetic resonance imaging, scientific investigations of treatment and rehabilitation effectiveness can be enhanced.