Western Neuro Sensory Stimulation Profile Research Articles

Changes of Spasticity Across Time in Prolonged Disorders of Consciousness: A Retrospective Study

<h3>Research Objectives</h3> To investigate how spasticity developed in patients diagnosed with a prolonged DOC over almost a two-year observation period (21months) and how it related to the patients' age, gender, time since injury, etiology, level of consciousness, and anti-spastic medications. <h3>Design</h3> Retrospective study. <h3>Setting</h3> Long-term care facility (Neurorestorative, CA). <h3>Participants</h3> Nineteen patients with severe brain injury and prolonged DOC admitted to a long-term care facility were included in the study (14 male, age: 45.8 ± 15.3 years, 10 traumatic brain injury, 1.01 ± 0.99 years after brain injury, 11 minimally conscious state vs. 8 vegetative state). <h3>Interventions</h3> None. <h3>Main Outcome Measures</h3> Each patient was assessed at admission and then quarterly totaling in eight assessments over 21 months. Spasticity was measured with the Modified Ashworth Scale (MAS) for both upper and lower limbs. The Western Neuro Sensory Stimulation Profile (WNSSP) was administered to assess the level of consciousness. The other medical and demographic information of interest were also obtained through medical records. <h3>Results</h3> Linear mixed models were used to assess each variable's impact on the change of spasticity over time. Significant differences were observed in the evolution of spasticity in patients based on their etiology for the upper limbs [F (7, 107.29) = 2.226, p = 0.038] and on their level of consciousness for the lower limbs [F (7, 107.07) = 3.196, p = 0.004]. <h3>Conclusions</h3> Our preliminary results suggest that spasticity evolves differently according to the type of brain lesion and the level of consciousness. Spasticity in DOC might therefore be mediated by different mechanisms and might have to be treated differently among patients. Future longitudinal studies should be performed prospectively in a bigger cohort and start data collection earlier after brain injury to confirm our results and better understand the evolution of spasticity in this population. <h3>Author(s) Disclosures</h3> The authors have nothing to declare

Changes of Spasticity across Time in Prolonged Disorders of Consciousness: A Retrospective Study.

Objectives: In this retrospective study, we investigated how spasticity developed in patients diagnosed with a prolonged DOC over an almost two-year observation period (21 months), and how it related to the patients’ age, gender, time since injury, etiology, level of consciousness, and anti-spastic medications. Methods: In total, 19 patients with a severe brain injury and prolonged DOC admitted to a long-term care facility were included in this study (14 male, age: 45.8 ± 15.3 years, 10 traumatic brain injury, 1.01 ± 0.99 years after brain injury, 11 minimally conscious state vs. 8 vegetative state). Each patient was assessed at admission and then quarterly, totaling eight assessments over 21 months. Spasticity was measured with the Modified Ashworth Scale (MAS) for both upper and lower limbs. The Western Neuro Sensory Stimulation Profile (WNSSP) was administered to assess the level of consciousness. Any other medical and demographic information of interest was obtained through medical records. Linear mixed models were used to assess each variable’s impact on the change of spasticity over time. Results: Significant differences were observed in the evolution of spasticity in patients based on their etiology for the upper limbs [F (7, 107.29) = 2.226; p = 0.038], and on their level of consciousness for the lower limbs [F (7, 107.07) = 3.196; p = 0.004]. Conclusion: Our preliminary results suggest that spasticity evolves differently according to the type of brain lesion and the level of consciousness. Spasticity in DOCs might therefore be mediated by different mechanisms and might have to be treated differently among patients. Future longitudinal studies should be performed prospectively in a bigger cohort and with data collection beginning earlier after brain injury to confirm our results and better understand the evolution of spasticity in this population.

Effect of integrative nursing practices on cognitive recovery among severe traumatic brain injury patients

Background and objective: Cognitive recovery after severe traumatic brain injury (TBI) is the biggest challenge facing the critical care nurses (CCNs). Several studies have been reported that the majority of CCNs are concerned with providing conventional nursing practices to severe TBI patients. These practices are directed to stabilize patients’ status rather than to enhance cognitive recovery after TBI. Application of integrative nursing practices for TBI patients can help in enhancing cognitive recovery. Aim: This study aimed to determine the effect of integrative nursing practices on cognitive recovery among severe traumatic brain injury patients.Methods: A quasi experimental research design was utilized. A convenience sample was conducted on 60 adult patients suffering from severe TBI who admitted to the intensive care units of Alexandria Main University Hospital. Patients were assigned into study group (30 patients) and control group (30 patients). One tool was used for data collection namely “Cognitive Recovery Assessment Tool”. This tool was used to assess recovery of cognitive function domains. It consists of level of consciousness using Full Outline of Un-Responsiveness (FOUR) score, level of cognitive functioning using Rancho Los Amigos (RLA) scale and basic cognitive sensory recovery assessment using Western Neuro Sensory Stimulation Profile (WNSSP) scale.Results: The implementation of integrative nursing practices for the study group was associated with statistically significant positive effects. Patients in the study group showed higher means of consciousness revealed by FOUR score and cognitive function revealed by RLA scale. The basic cognitive sensory recovery revealed by WNSSP scale in the study group was also significantly improved.Conclusions: Implementation of integrative nursing practices has been shown to enhance cognitive recovery among severe TBI patients. Thus, it is recommended for use in a nurse’s daily routine of care for severe TBI patients.

Comparing effects of sensory stimulation by nurses and family members on unconscious patients with severe traumatic brain injury

Objective To evaluate the clinical effects of sensory stimulation provided by nurses and family members respectively on waking up unconscious patients with severe traumatic brain injury. Methods A total of 92 unconscious patients with severe traumatic brain injury admitted in the Intensive Care Unit, Neurosurgery Department, Affiliated Hospital of Nantong University between May 2016 and May 2017 were selected and divided into two groups according to the random number table. Patients in the control group received sensory stimulation by nurses, while patients in the observation group received sensory stimulation by family members. The Glasgow Coma Scale (GCS), Western Neuro Sensory Stimulation Profile (WNSSP), Rancho Los Amigos Scale (RLA) and electroencephalogram examination (EEG) scores were compared between the two groups before and after the intervention. Results There was no statistical difference in the scores between the two groups before the sensory stimulation (P>0.05). Two weeks post the intervention, there were statistical differences between the control group and the observation group in GCS [(7.28±1.86) vs. (9.78±2.01)], WNSSP [(13.23±10.07) vs. (47.48±14.32)]and RLA [(2.15±0.98) vs. (3.20±1.30)]scores (P 0.05). Conclusions Sensory stimulation can enable the unconscious patients with severe traumatic brain injury to regain consciousness, cognitive and sensory functions. The sensory stimulation provided by caregivers is better than that by responsible nurses, and the former is better in accelerating the patients' rehabilitation. Key words: Brain injury; Coma, post-brain traumatic; Nurses; Caregivers; Sensory stimulation

Effects of a Sensory Stimulation by Nurses and Families on Level of Cognitive Function, and Basic Cognitive Sensory Recovery of Comatose Patients With Severe Traumatic Brain Injury: A Randomized Control Trial.

BackgroundSeveral lines of evidence suggest that early sensory stimulation and regular family visiting programs are potential nursing interventions to improve the outcomes of head injured comatose patients. However, little is known about the impacts of family involvement in providing sensory stimulation.ObjectivesTo determine the effects of a sensory stimulation program conducted by nurses and families on the consciousness, level of cognitive function, and basic cognitive sensory recovery of head injury comatose patients.Patients and MethodsThis was a randomized clinical trial performed at the Shiraz level I trauma center including 60 head injured comatose patients with an initial Glasgow coma score (GCS) of less than 8. Patients were randomly assigned to receive sensory stimulation by a qualified nurse (nurse group; n = 20), by the family (family group; n = 20), or usual care (control group; n = 20). The sensory stimulation program involving the nurses and patients’ families was conducted, twice daily, in the morning and evening for 7 days. The level of consciousness, level of cognitive function, and basic cognitive sensory recovery of the patients were evaluated and monitored using the GCS, Rancho Los Amigos (RLA), and Western Neuro-Sensory stimulation profile (WNSSP). Data were analyzed by chi square, Kruskal-Wallis, and repeated-measures tests using SPSS.ResultsAll the patients were comparable regarding their baseline characteristics, level of consciousness, level of cognitive function, and basic cognitive sensory recovery determined by GCS, RLA, and WNSSP. Although the two intervention groups of the study improved, those who received the sensory stimulation program from their families had significantly higher GCS (P = 0.001), RLA (P = 0.001), and WNSSP (P = 0.001) scores after 7 days when compared to the two other groups.ConclusionsThe application of sensory stimulation by families led to significant increases in the consciousness, level of cognitive function, and basic cognitive sensory recovery of comatose patients with severe injuries.

Multidisciplinary assessment measure for individuals with disorders of consciousness

Objective: This study introduces the Comprehensive Assessment Measure for the Minimally Responsive Individual (CAMMRI) and reports on its development, inter-rater reliability, construct validity and clinical value.Methods: A multidisciplinary team of therapists developed this measure, which comprises 12 sub-tests that examine three main areas: Response to the Environment, Motor Control and Communication and Swallowing. The sub-tests are scored using a 7-point scale; sub-tests can also be administered individually. The measure was administered during a pilot project and then 1 year later to 12 adult clients with severe acquired brain injury at a long-term rehabilitation programme. The age range of the participants was 18–65 years; individuals were 1.5–10 years post-injury.Results: Comparison measures included the Western Neuro Sensory Stimulation Profile (WNSSP), the Coma Recovery Scale-Revised (CRS-R) and the Chedoke McMaster Impairment Inventory (CMII). Inter-rater reliability of each sub-test ranged from 0.87–1.0, with an average of 0.90 in the first year of the assessments.Conclusion: Validity data supported the use of the CAMMRI for minimally conscious adults with ABI to measure behavioural changes and plan treatment for this population. Future research should focus on using this measure with other neurological populations.

Validating the Western Neuro Sensory Stimulation Profile for patients with severe traumatic brain injury who are slow-to-recover.

The Western Neuro Sensory Stimulation Profile (WNSSP) is designed to measure disorders of consciousness in people with severe traumatic brain injury who are slow-to-recover. This study explores internal consistency reliability and concurrent validity of the WNSSP with function and two other consciousness measures. Retrospective chart audit of all severe traumatic brain injury patients admitted to a specialist neurological rehabilitation centre from January 2001 to December 2006 in a vegetative or minimally conscious state. Medical record of demographical, clinical and Glasgow Coma Scale (GCS) data were recorded. To be included in the study, patients needed admission and discharge WNSSP results; plus Functional Independence Measure™ (FIM™) and Rancho Los Amigos Scale (RLAS) scores. Of 37 potential participants, 33 had required WNSSP results (mean age 28years; 27 male participants). Internal consistency reliability was very high (α=0.933). Concurrent validity in relation to function was significant but weak at admission for FIM™ Total-scale but not subscales (rs =-0.146, P=0.0424). At discharge, there was a modest relationship with FIM™ Motor-subscale (rs =0.374; P=0.045), and FIM™ Cognition-subscale (rs =0.412; P=0.026) scores, but not the FIM™ Total-scale. Concurrent validity in relation to the RLAS was strong at admission (rs =0.693, P=0.01) and discharge (rs =0.788, P=0.01). The WNSSP and GCS scores were not associated. The WNSSP is sensitive to behavioural change in slow-to-recover patients with severe traumatic brain injury. It demonstrates very high internal consistency reliability, and positive evidence of concurrent validity with FIM™ and the RLAS providing detailed description of cognitive-sensory behaviour within RLAS-levels.

Observed Recovery Sequence in Neurobehavioral Function After Severe Traumatic Brain Injury

The Western Neuro Sensory Stimulation Profile (WNSSP) presents a hierarchy of items suggestive of a sequence of recovery. The aim of this study was to understand the sequence of recovery of neurobehavioral function in patients with brain injury and determine whether this sequence was consistent with the WNSSP test item order. We conducted a retrospective clinical chart audit of 37 adult inpatients (mean age = 29 yr; 31 men, 6 women) with a diagnosis of traumatic brain injury and a minimum of two medical record entries on the WNSSP. The sequence of recovery was statistically derived from the content and structure of the WNSSP. Our analysis did not support the current item ordering of the WNSSP as a function of the sequence of recovery from coma, with the exception of the Arousal/Attention subscale. WNSSP item performance suggested a sequence of recovery; clinicians may consider a revised item order that reflects this observed order.

Effect of frequency of multimodal coma stimulation on the consciousness levels of traumatic brain injury comatose patients

Objectives: To evaluate the effectiveness of multimodal coma stimulation on the conscious levels of head injury comatose patients and to find out which of the two protocols of coma stimulation, i.e. administrating twice a day or 5-times a day is more beneficial.Methods: Thirty comatose patients with traumatic head injury (GCS < 8) were selected and were divided into three groups randomly. Group A (n = 10) received multimodal coma stimulation 5-times a day (20 minutes each session), Group B (n = 10) received stimulation twice a day (50 minutes each session) and Group C (n = 10) received conventional physiotherapy twice daily. Subjects in all the three groups received treatment for 2 weeks.Results and conclusion: The results showed a significant difference (p < 0.01) for Glasgow Coma Scale as well as Western Neuro Sensory Stimulation Profile scores between Groups A & C and B & C, i.e. multimodal coma stimulation is effective as compared to the control group. The results also revealed a significant difference (p < 0.01) between Groups A, B and C on the Western Neuro Sensory Stimulation Profile but a non-significant difference (p > 0.01) on the Glasgow coma scale. This indicates that short sessions of high frequency can be more beneficial.

Course of recovery and prediction of outcome in young patients in a prolonged vegetative or minimally conscious state after severe brain injury: An exploratory study

To explore the course of recovery of consciousness and factors predicting the outcome of severe brain injury with a prolonged period of unconsciousness in children and young adults receiving a specialized rehabilitation treatment, the Early Intensive Neurorehabilitation Programme (EINP). A cohort of forty-four patients aged 1.6-25.5 years (M=16.0) with traumatic acquired brain injury (TBI) or non-traumatic acquired brain injury (nTBI) were examined using the Western Neuro Sensory Stimulation Profile every two weeks, from the application for EINP until discharge. The level of consciousness was assessed with the Post-Acute Level of Consciousness Scale, and the level of disability was determined by the Disability Rating Scale. Long-term level of disability of all TBI patients (N=32) was assessed between 2.0 and 4.4 years after discharge from EINP. Two-thirds of all patients recovered to consciousness. Three recovery patterns were identified: remaining in a vegetative state (VS), slow recovery of consciousness, and fast recovery of consciousness. In the long-term, 11 of the TBI patients were severely disabled, 13 were moderately disabled, and 4 were mildly disabled. All TBI patients who were in VS at discharge either had deceased, or recovered to a very severely disabled state. Three recovery patterns identified in an early stage after starting EINP made it possible to predict long-term level of disability.

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.

Assessing the relationship between the WNSSP and therapeutic participation in adolescents in low response states following severe traumatic brain injury

Primary objective: This study examines the relationship between scores on the Western Neuro Sensory Stimulation Profile (WNSSP) and therapeutic participation as it relates to rehabilitation readiness (RR) in adolescents with low response following severe traumatic brain injury (TBI).Research design: This is a serial observational design using multiple measures of clinical status and participation.Methods and procedures: Ten children, mean age 16.7 years, who remained in a low response state (30 days or more) were assessed with the WNSSP and videotaped during physical and occupational therapy sessions. Associations were evaluated between WNSSP scores and participation scores related to arousal, awareness and communication.Main outcomes and results: The WNSSP was only associated with the communication score (p < 0.0001). The arousal and awareness scores had no significant impact on the WNSSP score.Conclusions: These results suggest that scores on the WNSSP may be related to the return of communication skills in adolescents in low response states as one part of assessing their therapeutic participation and ultimate rehabilitation readiness. This ability may assist in making decisions regarding care planning.

The reliability and validity of the PALOC-s: A Post-Acute Level of Consciousness scale for assessment of young patients with prolonged disturbed consciousness after brain injury

The objective of the study was the validation of the Post-Acute Level of Consciousness scale (PALOC-s) for use in assessing levels of consciousness of severe brain injured patients in a vegetative state or in a minimally conscious state. A cohort of 44 successively admitted patients (between 2 and 25 years of age), who were treated in an early intensive neurorehabilitation programme, were included in the study. Each patient was examined, using the Western Neuro Sensory Stimulation Profile (WNSSP) and the Disability Rating Scale (DRS), once every two weeks resulting in 327 examinations (all videotaped). To determine the reliability of the PALOC-s, six observers rated one videotape of each patient. One of the observers rated the same tapes a second time, 3–4 months later. Validity was determined by correlating 100 ratings of one observer with the scores on the WNSSP and the DRS. To determine the responsiveness of the PALOC-s, the size of change between the scores of the first and last examinations was calculated. The inter-observer correlations and agreement scores varied between .82 and .95. The intra-observer correlation and agreement scores varied between .94 and .96. Correlations with the WNSSP varied between .88 and .93, and with the DRS between .75 and .88. The responsiveness was significantly high (t = 8.2), with a standardised effect size of 1.30. It is concluded that the PALOC-s is a reliable, valid, and responsive observation instrument provided it is administered after a structured assessment by an experienced and trained clinician. The PALOC-s is feasible for use in clinical management, as well as in outcome research.

Assessment of visual pursuit in post-comatose states: use a mirror

One of the first clinical signs differentiating the minimally conscious state (MCS) from the vegetative state is the presence of visual pursuit occurring in direct response to moving or salient...

Sequence of Recovery During the Course of Emergence From the Minimally Conscious State

Taylor CM, Aird VH, Tate RL, Lammi MH. Sequence of recovery during the course of emergence from the minimally conscious state. Objective To document and examine recovery profiles of persons during the course of emergence from a minimally conscious state (MCS) after traumatic brain injury (TBI). Design Case series. Setting Participants in an inpatient brain injury rehabilitation program. Participants Nine people with TBI who emerged from MCS. Interventions Not applicable. Main Outcome Measure The Western Neuro Sensory Stimulation Profile. Results In all cases, stereotyped (nonreflexive) movement was the first behavior to resolve, yet by itself it was never sufficient to indicate emergence from the MCS. Two of the 9 patients showed consistent object manipulation before all 3 elements of functional communication. Conversely, in 2 patients, all 3 components of functional communication emerged before object manipulation. In the remaining 5 patients, object manipulation occurred along with components of functional communication. Conclusions During the course of data collection, issues were raised about differentiation between the MCS and posttraumatic amnesia. The data are also discussed within the context of the work of Giacino et al and the development of their scale to measure duration of the MCS. These data support the theory that functional communication and object manipulation are the 2 key indicators of emergence from MCS.

Dopamine Agonist Therapy in Low-Response Children Following Traumatic Brain Injury

The objective of this study was to determine whether a dopamine agonist could improve mental status among children in a low-response state following traumatic brain injury. In an 8-week, prospective, double-blind, randomized trial, 10 children and adolescents ages 8 to 21 years (X = 16.7 years) with traumatic brain injury sustained at least 1 month previously and remaining in a low-response state (Rancho Los Amigos Scale level pound 3) received pramipexole or amantadine. Medication dosage was increased over 4 weeks, weaned over 2 weeks, and then discontinued. At baseline and weekly during the study, subjects were evaluated with the Coma Near Coma Scale, Western NeuroSensory Stimulation Profile, and Disability Rating Scale. Scores improved significantly from baseline to the medication phase on the Coma Near Coma Scale, Western NeuroSensory Stimulation Profile, and Disability Rating Scale (P < .005). The weekly rate of change was significantly better for all three measures on medication than off medication (P < .05). Rancho Los Amigos Scale levels improved significantly on medication as well (P < .05). There was no difference in efficacy between amantadine and pramipexole. No unexpected or significant side effects were observed with either drug. This clinical trial supports the benefit of two dopamine agonists in the restoration of functional arousal, awareness, and communication. These drugs can be helpful in accelerating eligibility for acute rehabilitation among children and adolescents who have sustained significant brain injuries.

The minimally conscious state and recovery potential: A follow-up study 2 to 5 years after traumatic brain injury

Lammi MH, Smith VH, Tate RL, Taylor CM. The minimally conscious state and recovery potential: a follow-up study 2 to 5 years after traumatic brain injury. Arch Phys Med Rehabil 2005;86:746–54. Objective To document recovery in persons who were in the minimally conscious state (MCS) for at least 1 month after traumatic brain injury (TBI). Design Patient series. Setting Participants who had been discharged from an inpatient rehabilitation unit. Participants Eighteen people with TBI and their relatives. Interventions Not applicable. Main outcome measures Western Neuro Sensory Stimulation Profile, Disability Rating Scale (DRS), FIM instrument, Dementia Rating Scale, and Sydney Psychosocial Reintegration Scale (SPRS). Results Level of functioning at follow-up varied from extremely severe disability or greater on the DRS (n=4) to mild disability (n=1). These outcomes were corroborated by results of the FIM and the Dementia Rating Scale. All participants experienced some (44%) or major (56%) change in their level of psychosocial functioning on the SPRS compared with their preinjury level. There were no significant correlations between duration of time in the MCS and outcome on FIM, DRS, or SPRS. Conclusions These results highlight the heterogeneity of outcome even after a prolonged duration of MCS after TBI. A large proportion of the patients was functionally independent in basic daily activities, although all experienced residual impairments and disabilities. The low correlation coefficients between duration of MCS and the outcome measures suggest that prognostic statements based on length of time a person is in the MCS cannot be made with confidence.

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.

The sensory modality assessment and rehabilitation technique (SMART): a valid and reliable assessment for vegetative state and minimally conscious state patients

Primary objective: To establish the reliability and validity of the Sensory Modality Assessment and Rehabilitation Technique (SMART) as a tool for discriminating awareness in patients with profound brain damage.Research design: A comparative prospective study was conducted.Method and procedures: Sixty subjects diagnosed in vegetative state (VS) on admission were assessed at 2-monthly intervals. Rancho level ratings derived from referring physicians, SMART and Western Neuro Sensory Stimulation Profile (WNSSP) scores were compared.Main outcomes and results: The intra-observer intra class correlation (ICC) was 0.97 and inter-observer ICC was 0.96, implying very little within and between observer scoring variations. A modest, although significant correlation was established between SMART and either physician or WNSSP scores. However, the correlation between the WNSSP and SMART was higher (r = 0.70) than that between WNSSP and physicians scores (r = 0.451) or between SMART and physicians (r = 0.474).Conclusion: SMART is a valid and reliable assessment for discriminating awareness in VS and Minimally Conscious State (MCS).

A comparison of a behavioural assessment tool and electrophysiological measures of recovery from coma

The Wessex Head Injury Matrix (WHIM) [1] is one of the rare behavioural scales that have been designed to follow the recovery of head-injured patients throughout the whole spectrum of altered states of consciousness, from exit of coma to complete recovery. In this study, we explored the validity of the WHIM in relation to other behavioural assessment tools – Glasgow–Liege Coma Scale (GLS) [2], Coma-Near Coma scale (CNC) [3], Western Neuro Sensory Stimulation Profile (WNSSP) [4] – as well as in relation to the Bi-Spectral Index (BIS), derived from electroencephalographic measures. Twenty-nine brain-injured comatose patients (aged 21–83 years) were followed longitudinally with these behavioural and electrophysiological measures. Overall, the evolution of the scores on the WHIM correlated significantly with the evolution of scores obtained by the GLS (r = 0.88; P < 0.01), the CNC (r = -0.8; P < 0.01), the WNSSP (r = 0.87; P < 0.01), as well as with the BIS measure (r = 0.58; P < 0.01). Relative to the GLS, CNC and WNSSP, the WHIM showed a particularly good sensitivity for documenting subtle changes in recovery for patients in a minimally conscious state. The BIS index globally evolved in parallel to the behavioural scales. However, it showed a very bad sensitivity as many patients in a coma or a vegetative state presented BIS scores that were as high as those observed for patients that had regained normal consciousness. The results confirm the usefulness of the WHIM, especially for the assessment of minimally conscious patients. However, even if a global relation is observed with behavioural scales, the validity of electrophysiological measures such as the BIS index is unsatisfactory for the assessment of altered states of consciousness.