[en] This paper reviews the current state of bedside behavioral assessment in brain-damaged patients with impaired consciousness (coma, vegetative state, minimally conscious state). As misdiagnosis in this field is unfortunately very frequent, we first discuss a number of fundamental principles of clinical evaluation that should guide the assessment of consciousness in brain-damaged patients in order to avoid confusion between vegetative state and minimally conscious state. The role of standardized behavioral assessment tools is particularly stressed. The second part of this paper reviews existing behavioral assessment techniques of consciousness, showing that there are actually a large number of these scales. After a discussion of the most widely used scale, the Glasgow Coma Scale, we present several new promising tools that show higher sensitivity and reliability for detecting subtle signs of recovery of consciousness in the post-acute setting.
Disciplines :
Neurology Neurosciences & behavior
Author, co-author :
Majerus, Steve ; Université de Liège - ULiège > Département des sciences cognitives > Psychopathologie cognitive
Gill-Thwaites, Helen
Andrews, Keith
Laureys, Steven ; Université de Liège - ULiège > Centre de recherches du cyclotron
Language :
English
Title :
Behavioral Evaluation of Consciousness in Severe Brain Damage
Publication date :
2005
Journal title :
Progress in Brain Research
ISSN :
0079-6123
eISSN :
1875-7855
Publisher :
Elsevier, Netherlands
Volume :
150
Issue :
Boundaries of Consciousness: Neurobiology and Neuropathology
K. Andrews, L. Murphy, R. Munday, and C. Littlewood Misdiagnosis of the vegetative state: retrospective study in a rehabilitation unit Bri. Med. J. 313 1996 13 16
K. Andrews International Working Party on the Management of the Vegetative State: summary report Brain Inj. 10 1996 797 806
B.J. Ansell, and J.E. Keenan The Western neuro sensory stimulation profile: a tool for assessing slow to recover head injured patients Arch. Phys. Med. Rehabil. 70 1989 104 108
A. Benzer, G. Mitterschiffthaler, M. Marosi, G. Luef, F. Puhringer, K. De La Renotiere, H. Lehner, and E. Schmutzhard Prediction of non-survival after trauma: Innsbruck Coma Scale Lancet 338 1991 977 978
J.L. Bernat The boundaries of the persistent vegetative state J. Clin. Ethics 3 1992 176 180
J.D. Born The Glasgow-Liège Scale. Prognostic value and evaluation of motor response and brain stem reflexes after severe head injury Acta Neurochir. 95 1988 49 52
J.D. Born, P. Hans, G. Dexters, K. Kalangu, J. Lenelle, G. Milbouw, and A. Stevenaert Practical assessment of brain dysfunction in severe head trauma Neurochirurgie 28 1982 1 7
W.F. Bouzarth Neurosurgical watch sheet for craniocerebral trauma J. Trauma 8 1968 29 31
A. Bricolo, S. Turazzi, A. Alexandre, and N. Rizzuto Decerebrate rigidity in acute head injury J. Neurosurg. 47 1977 680 689
A. Bricolo, S. Turazzi, and G. Feriotti Prolonged posttraumatic unconsciousness: therapeutic assets and liabilities J. Neurosurg. 52 1980 625 634
A. Canedo, M.C. Grix, and J. Nicoletti An analysis of assessment instruments for the minimally responsive patient (MRP): clinical observations Brain Injury 16 2002 453 461
N.L. Childs, W.N. Mercer, and H.W. Childs Accuracy of diagnosis of persistent vegetative state Neurology 43 1993 1465 1467
L. Crosby, and L.C. Parsons Clinical neurologic assessment tool: development and testing of an instrument to index neurologic status Heart Lung 18 1989 121 129
A.L. Davis The visual response evaluation: a pilot study of an evaluation tool for assessing visual responses in low-level brain injured patients Brain Injury 5 1991 315 320
E.A. Freeman The coma exit chart: assessing the patient in prolonged coma and vegetative state Brain Injury 10 1996 615 624
G.G. Gallup Jr. On the rise and fall of self-conception in primates Ann. NY Acad. Sci. 818 1997 72 82
J.T. Giacino, S. Ashwal, N. Childs, R. Cranford, B. Jennett, D. Katz, J. Kelly, J. Rosenberg, J. Whyte, R. Zafonte, and N. Zasler The minimally conscious state: definition and diagnostic criteria Neurology 58 2002 349 353
J.T. Giacino, M.A. Kezmarsky, J. DeLuca, and K.D. Cicerone Monitoring rate of recovery to predict outcome in minimally responsive patients Arch. Phys. Med. Rehab. 72 1991 897 901
J.T. Giacino, and N.D. Zasler Outcome after severe traumatic brain injury: Coma vegetative state and the minimally responsive state J. Head Trauma Rehab. 10 1995 40 56
J.T. Giacino, K. Kalmar, and J. Whyte The JFK Coma Recovery Scale - Revised: measurement characteristics and diagnostic utility Arch. Phys. Med. Rehab. 85 2004 2020 2029
J.T. Giacino, and J. Whyte The vegetative and minimally conscious states: current knowledge and remaining questions J. Head Trauma Rehab. 20 2005 30 50
H. Gill-Thwaites The sensory modality assessment and rehabilitation technique - a tool for the assessment and treatment of patients with severe brain injury in a vegetative state Brain Injury 11 1997 723 734
H. Gill-Thwaites, and R. Munday The sensory modality assessment and rehabilitation technique (SMART): a comprehensive and integrated assessment and treatment protocol of the vegetative state and minimally responsive patient Neuropsychol. Rehabil. 9 1999 305 320
H. Gill-Thwaites, and R. Munday The sensory modality assessment and rehabilitation technique (SMART). A valid and reliable assessment for vegetative state and minimally conscious state patients Brain Injury 18 2004 1255 1269
C. Hagen, D. Malkmus, and P. Durham Levels of Cognitive Function Rehabilitation of Head Injured Adults: Comprehensive Physical Management 1979 Profession Staff Association of Rancho Los Amigos Hospital Inc. Downey, CA
S. Horn, M. Watson, B.A. Wilson, and D.L. McLellan The development of new techniques in the assessment and monitoring of recovery from severe head injury: a preliminary report and case history Brain Injury 6 1992 321 325
S. Horn, A. Shiel, D.L. McLellan, M. Campbell, M. Watson, and B.A. Wilson A review of behavioural assessment scales for monitoring recovery in and after coma with pilot data on a new scale of visual awareness Neuropsychol.Rehabil 3 1993 121 137
L.P. Ivan Spinal reflexes in cerebral death Neurology 23 1973 650 652
B. Jennett Prognosis after severe head injury Clin. Neurosurg. 19 1972 200 207
B. Jennett, and G. Teasdale Aspects of coma after severe head injury Lancet i 1977 878 881
S. Laureys, S. Majerus, and G. Moonen Assessing consciousness in critically ill patients J.L. Vincent Yearbook of Intensive Care and Emergency Medicine 2002 Springer Berlin 715 727
S. Majerus, M. Van der Linden, and F. Damas Les états de conscience altérée: comment les définir et comment les évaluer? Rev. Neuropsychol. 10 2000 219 254
S. Majerus, M. Van der Linden, and A. Shiel Wessex Head Injury Matrix and Glasgow/Glasgow-Liège Coma Scale: a validation and comparison study Neuropsychol. Rehabil. 10 2000 167 184
Majerus, S., Azouvi, P., Fontaine, A., Marlier, N., Tissier, A.-C. and Van der Linden, M. (2001). Adaptation française de la Wessex Head Injury Matric - 62 items. Unpublished test manual.
D.W. Marion, and P.M. Carlier Problems with initial Glasgow Coma Scale assessment caused by prehospital treatment of patients with head injuries: results of a national survey J. Trauma 36 1994 89 95
L.S. Murray, G.M. Teasdale, G.D. Murray, B. Jennett, J.D. Miller, J.D. Pickard, M.D. Shaw, J. Achilles, S. Bailey, and P. Jones Does prediction of outcome alter patient management? Lancet 341 1993 1487 1491
A.K. Ommaya Trauma to the nervous system Ann. Roy. Coll. Surg. 39 1966 317 347
F. Plum, and J.B. Posner The Diagnosis of Stupor and Coma 1983 Davis, F.A. Philadelphia, PA
M.A. Rader, and D.W. Ellis The sensory stimulation assessment measure (SSAM): A tool for early evaluation of severely brain-injured patients Brain Injury 8 1994 309 321
M. Rappaport, A.M. Dougherty, and D.L. Kelting Evaluation of coma and vegetative states Arch. Phys. Med. Rehab. 73 1992 628 634
G. Rowley, and K. Fielding Reliability and accuracy of the Glasgow Coma Scale with experienced and inexperienced users Lancet 337 1991 535 538
Royal College of Physicians The Vegetative State. Guidance on diagnosis and management 2003 Publication Unit of the Royal College of Physicians London
M. Salcman, R.S. Schepp, and T.B. Ducker Calculated recovery rates in severe head trauma Neurosurgery 8 1981 301 308
G. Saposnik, J.A. Bueri, J. Maurino, R. Saizar, and N.S. Garretto Spontaneous and reflex movements in brain death Neurology 54 2000 221 223
M. Segatore, and C. Way The Glasgow Coma Scale: time for change Heart Lung 21 1992 548 557
A. Shiel, S. Horn, B.A. Wilson, D.L. McLellan, M. Watson, and M. Campbell The Wessex Head Injury Matrix main scale: a preliminary report on a scale to assess and monitor patients recovery after severe head injury Clin. Rehabil. 14 2000 408 416
D. Stalhammar, J.E. Starmark, E. Holmgren, N. Eriksson, C.H. Nordstrom, O. Fedders, and B. Rosander Assessment of neurological responsiveness in acute cerebral disorders. Multicenter study on the Reaction Level Scale (RLS85) Acta Neurochir. 90 1988 73 80
D.E. Stanczak, J.G. White 3rd, W.D. Gouview, K.A. Moehle, M. Daniel, T. Novack, and C.J. Long Assessment of level of consciousness following severe neurological insult. A comparison of the psychometric qualities of the Glasgow Coma Scale and the Comprehensive Level of Consciousness Scale J. Neurosurg. 60 1984 955 960
G. Teasdale Acute impairment of brain function-1. Assessing 'conscious level' Nurs. Times 71 1975 914 917
G. Teasdale, and B. Jennett Assessment of coma and impaired consciousness. A practical scale Lancet 2 1974 81 84
G. Teasdale, and B. Jennett Assessment and prognosis of coma after head injury Acta Neurochir. 34 1976 45 55
G. Teasdale, B. Jennett, L. Murray, and G. Murray Glasgow Coma Scale: to sum or not to sum Lancet 2 1983 678
The Multi-Society Task Force on PVS Medical aspects of the persistent vegetative state (First of Two Parts) New Engl. J. Med. 330 1994 1499 1508
D.D. Tresch, H.S. Farrol, E.H. Duthie, M.D. Goldstein, and P.S. Lane Clinical characteristics of patients in the persistent vegetative state Arch. Int. Med. 151 1991 930 932
M. Watson, and S. Horn Paired preferences technique: an alternative method for investigating sequences of recovery in assessment scales Clin. Rehabil. 6 1992 170
M. Watson, S. Horn, A. Shiel, and D.L. McLellan The application of a paired comparisons technique to identify sequence of recovery after severe head injury Neuropsychol. Rehabil. 7 1997 441 458
J. Whyte, and M. DiPasquale Assessment of vision and visual attention in minimally responsive brain injured patients Arch. Phys. Med. Rehab. 76 1995 804 810
J. Whyte, M. DiPasquale, and M. Vaccaro Assessment of command-following in minimally conscious brain injured patients Arch. Phys. Med. Rehab. 80 1999 1 8
B.A. Wilson, A. Shiel, M. Watson, S. Horn, and D.L. McLellan Monitoring behaviour during coma and post-traumatic amnesia B. Uzell A.L. Christensen Progress in the Rehabilitation of Brain Injured People 1994 Lawrence Erlbaum Associates Inc. Hillsdale, NJ
F.C. Wilson, J. Harper, T. Watson, and J.I. Morrow Vegetative state and minimally responsive patients: regional survey, long-term case outcome and service recommendations NeuroRehabilitation 17 2002 231 236
S.L. Wilson, G.E. Powell, K. Elliot, and H. Thwaites Sensory stimulation in prolonged coma - four single case studies Brain Injury 5 1991 393 401
S.L. Wilson, G.E. Powell, K. Elliot, and H. Thwaites Evaluation of sensory stimulation as a treatment for prolonged coma - seven single experimental case studies Neuropsychol. Rehabil. 3 1993 191 201
S.L. Wilson, D. Brock, G.E. Powell, H. Thwaites, and K. Elliot Constructing arousal profiles for vegetative state patients - a preliminary report Brain Injury 10 1996 105 113
S.L. Wilson, G.E. Powell, D. Brock, and H. Thwaites Vegetative state and response to sensory stimulation: an analysis of twenty four cases Brain Injury 10 1996 807 818
S.L. Wilson, and H. Gill-Thwaites Early indications of emergence from vegetative state derived from assessment with the SMART - a preliminary report Brain Injury 14 2000 319 331
Working Group of the Royal College of Physicians The permanent vegetative state J Roy. Coll. Phys. Lond. 30 1996 119 121