Coma Recovery Scale - Revised

Last Updated

September 01, 2020

Revised Manual (2020)

Purpose

CRS-R a standardized neurobehavioral assessment measure designed for use in patients with disorders of consciousness. The scale is intended to be used to establish diagnosis, monitor behavioral recovery, predict outcome, and assess treatment effectiveness.

Link to Instrument

Instrument Details

Acronym CRS-R

Area of Assessment

Cognition
Language
Vision & Perception
Communication
Functional Mobility

Assessment Type

Observer

Cost

Free

Cost Description

<$20 for common objects. Use of the CRS-R is free under some circumstances, but a license is required for research or commercial use. More information may be obtained here: https://spauldingrehab.org/research/programs-labs/rehabilitation-outcomes-center/crs-r.

CDE Status

NINDS CDE Notice of Copyright
JFK Coma Recovery Scale- Revised

Classification

Supplemental for Traumatic Brain Injury (TBI).

Diagnosis/Conditions

Brain Injury Recovery

Brain Injury

The CRS-R consists of 6 subscales designed to assess auditory function, receptive and expressive language, visuoperception, communication ability, motor functions, and arousal level.
The 6 subscales are comprised of hierarchically-arranged items reflecting brainstem, subcortical, and cortically-mediated behaviors:
1. Auditory
2. Visual
3. Motor
4. Oromotor
5. Communication
6. Arousal Functions
Minimum score: 0
Maximum score: 23
Lowest item on each subscale represents reflexive activity while the highest item represents cognitively-mediated behaviors.
Scoring is standardized based on the presence or absence of operationally-defined behavioral criteria. Most items must be administered to obtain a score, although some behaviors (e.g., speech) can be scored when they occur spontaneously.
Behavioral responses must be clearly-discernible before they are scored present.
While the CRS-R total score should not be relied upon to establish a diagnosis, a total score of 10 or greater indicates a diagnosis of MCS or eMCS.
The CRS-R can also be used to differentiate patients into “MCS+” and “MCS-” subgroups, based on the presence or absence of receptive or expressive language function. (Thibaut, 2019)

Number of Items

Instruction manual
Scoring sheet
2 common objects (cup, comb, etc.)
An object that produces a loud noise
ADL objects (toothbrush, phone, etc)
Hand mirror
Brightly coloured object
Baseball sized ball
Pencil
Tongue depressor

15-30 minutes

Required Training

Reading an Article/Manual

Required Training Description

While there is no mandated training, a recommended training program, “Ten Guiding Principles for Administration and Scoring” and the FAQs are available at the top of this page under “Downloads”. Information about the answer key is in the "Considerations" section.

The CRS-R should be performed by a trained clinician or research investigator.

Child

6 - 12

years

Adolescent

13 - 17

years

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Initially reviewed by Erin Donnelly, PT, MSPT, NCS and the TBI EDGE task force of the Neurology Section of the APTA in 6/2012.

Updated in 2020 by:

Yelena Bodien, PhD

Srivatsan Uchani, BA

Alyssa Taubert, OTD, CBIS

Joseph Giacino, PhD

Camille Chatelle, PhD

Affiliation: Spaulding Rehabilitation Hospital, Boston MA

ICF Domain

Body Structure
Body Function

Measurement Domain

Cognition
Motor
Emotion

Professional Association Recommendation

American Congress of Rehabilitation Medicine (ACRM)
National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR)
American Academy of Neurology (AAN)
National Institute of Neurologic Disorders and Stroke (NINDS)
Neurology section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (SCI EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE)

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

For detailed information about how recommendations were made, please visit: http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

Abbreviations:

HR	Highly Recommend
R	Recommend
LS / UR	Reasonable to use, but limited study in target group / Unable to Recommend
NR	Not Recommended

Recommendations based on level of care in which the assessment is taken:

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

TBI EDGE

Recommendations for use based on ambulatory status after brain injury:

	Completely Independent	Mildly dependant	Moderately Dependant	Severely Dependant
TBI EDGE	N/A	N/A	N/A	N/A

Recommendations for entry-level physical therapy education and use in research:

	Students should learn to administer this tool? (Y/N)	Students should be exposed to tool? (Y/N)	Appropriate for use in intervention research studies? (Y/N)	Is additional research warranted for this tool (Y/N)
TBI EDGE	Yes	Yes	Yes	Not reported

Considerations

The examiner should communicate with medical or nursing staff to identify any contraindications or precautionary measures that should be taken before initiating CRS-R assessment.
There are no specific guidelines governing the frequency of CRS-R administration. Best practice suggests that up to five assessments may be required to capture the optimal level of function. (Wannez 2017)
The frequency of assessment is also dependent upon the rate of change in performance on the CRS-R, which is usually associated with the length of time post-injury.
We recommend discontinuing use of the CRS-R when all three of the following behaviors have been elicited, concurrently, on three consecutive examinations conducted over two weeks:
- Consistent movement to command (Auditory Subscale = 4)
- Reliable yes-no responses (Communication Subscale = 2)
- Focused attention (Arousal Subscale = 3)
If there is doubt as to whether the behavior meets the required criteria, the item should not be scored as being present and the next item down should be administered. A rule-of-thumb for determining level of certainty is whether the examiner believes that at least nine out of ten observers would agree the response criteria were met.
The CRS-R should be administered and scored as described in the manual. However, certain items or subscales may have to be omitted due to patient-specific factors. If one or more subscales are omitted, the total score cannot be obtained.
When CRS-R items cannot be administered or scored in a valid manner, a Test Completion Code should be used to indicate that the examination is confounded.
The CRS-R has been translated and re-validated in Spanish (Tamashiro 2014), Italian (Estraneo 2015), French (Schnakers 2008b), Portuguese (Simoes 2011), Norwegian (Lovstad et al., 2010), Russian (Iazeva 2018), German (Maurer-Karattup 2010), Polish (Binder 2018), Korean (Han 2018), and Chinese (Zhang 2019). The CRS-R is also available in Dutch, Swedish, Danish, and Greek, but has not been re-validated in these languages.
The pediatric version of the CRS-R, the Coma Recovery Scale for Pediatrics (CRS-P) should be used when assessing children between the ages of one and five who have not yet completed language and motor development (Slomine 2019).
In a review of scales that assess DoC, CRS-R was the only scale recommended with minor reservations. This recommendation was supported by expert consensus that the CRS-R has excellent content validity and acceptable standardized administration and scoring procedures. Studies provide evidence that the CRS-R probably has good interrater reliability and good internal consistency and possibly has excellent test-retest reliability. (Seel 2010)
The CRS-R satisfies all the criteria required for interval measurement (ie, unidimensionality, local independence, item invariance, absence of differential item function across diagnostic groups) (La Porta 2013; Gerrard 2014)

For more information or to request the Answer Key for the written test portion of the training module please contact:

Michael J.G. Bergin, PhD

Laboratory Manager

Neurorehabilitation Laboratory

Spaulding Rehabilitation Hospital Neurorehabilitation Lab
mjbergin@partners.org

Yelena G. Bodien, PhD

Research Scientist

Spaulding Rehabilitation Hospital Neurorehabilitation Lab

ybodien@mgh.harvard.edu

Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

Cut-Off Scores

Bodien, 2016; n = 252; Mean Age = 49 years (19.7); Mean Time Post-TBI = 48 (53) days; traumatic or non-traumatic DoC

A cut-off score of 8 provides the best balance between sensitivity and specificity for detecting consciousness, accurately classifying 93% of cases. A total score of 8 yields a true positive rate of 93%, true negative rate of 96% and diagnostic accuracy rate of 93%
CRS-R total score of 10 or higher yielded a sensitivity of 0.78 for correct identification of patients in MCS or EMCS, and specificity of 1.00 for correct identification of patients who did not meet criteria for either of these diagnoses (i.e., diagnosed with VS or coma). All patients with a total score of greater than or equal to 10 are therefore MCS or eMCS, per CRS-R criteria.
The “optimal” total score cut-off will vary depending on the user's objective

CRS-R Total Score Cut-off	7	8	9	10	11
Sensitivity	0.97	0.93	0.88	0.78	0.73
Specificity	0.80	0.963	0.97	1	1
Accuracy	0.921	0.937	0.905	0.841	0.802

Chatelle, 2016; n = 1190; Mean Age = 43 (20); Mean Time Post-injury = 162 (568) days; DoC patients; English- and French-speaking sample

Determined CRS-R subscore combinations that are unlikely to co-occur
Unlikely subscore combinations should be examined for administration error, scoring error, or underlying confounding factors that could invalidate the assessment

Disorder of Consciousness (TBI, CVA, hypoxic-ischemic BI, tumor): (Giacino J, Kalmar K, Whyte J, 2004; n= 80; mean age= 38.86 years(range 17-79 years old); mean time post injury= 58.43 days, range 21-249 days and Lovstad et al, 2010; n=31 with severe brain injury, median age 33 years, median days post injury 143).

CRS-R subscale	Vegetative State	Minimally Conscious State	Emergence from Minimally Conscious State (MCS+)
Auditory	Less than or equal to 2 and	3-4 OR
Visual	Less than or equal to 1 and	2-5 OR
Motor	Less than or equal to 2 and	3-5 OR	6 OR
Oromotor/verbal	Less than or equal to 2 and	3 OR
Communication	0	1	2-3

In order to be designated in the vegetative state all of the scores in column 2 must be met, however minimally conscious state can be achieved by the demonstration of only one of the score ranges in column 3, likewise emergence from MCS occurs with higher scores in motor or communication subscales.

Normative Data

Chatelle, 2016; n = 1190; Mean Age = 43 (20); Mean Time Post-injury = 162 (568) days; DoC patients; English- and French-speaking sample)

Mean admission CRS-R total score= 8.5±5.1

Giacino, 2004; n = 80; Mean Age = 38.86 (13.18) [validity study], 36.70 (12.40) [reliability study]; Time Post-injury = 58.43 (30.80) [validity study], 57.15 (26.90) [reliability study]; traumatic and non-traumatic brain injury

Median CRS-R total score = 12.00

Iazeva, 2018; n = 58; Median Age = 46 (18); Mean Time Post-injury = 2.5 (1) months; traumatic and non-traumatic brain injury; Russian sample

Median CRS-R total score after the first visit was 8.5 [5.0; 14.75] and after the second visit was 10.0 [5.0; 17.75], р<0.0001
Total CRS-R score was 5 [4.5; 6.0] in the group of VS patients vs. 13 [10; 19] in the MCS group (p<0.0001)

Test/Retest Reliability

Test-retest reliability was excellent for CRS-R total scores (ρ=.94, P<.001), demonstrating adequate stability in patient performance over a brief assessment interval (i.e., 36h)
Cross-correlation, representing the relationship between scores obtained by different raters on different days, was the lowest of the 3 pairs of ratings (ρ=.79, P<.001)
No systematic difference in the scores obtained by different raters on different days (P=.80) or by different raters on the same day (P=.10)
Scores obtained by the same rater (ie, rater A) on different days, however, differed significantly (P=.02)
Test-retest reliability was high for the total CRS-R score and there was relatively good agreement between the scores of different raters on different days
Test-retest reliability was adequate for all subscales except the oromotor/verbal, on which scores were systematically higher on day 2
In view of these findings, scores on the visual and oromotor/verbal subscales should be used cautiously. Taken together, the results of these analyses suggest that the CRS-R can be used reliably

Test-Retest Reliability of Dichotomized CRS-R Subscale Scores (n=20)

Subscale	Cohen kappa	95% CI	P	Rater Agreement
Auditory	0.63	±.35	.00	85%
Visual	0.90	±.19	.00	95%
Motor	1.00	±.00	.00	100%
Oromotor/Verbal	0.23	±.51	.17	70%
Communication	0.89	±.22	.00	95%

Han, 2018; n = 39; Mean Age = 56.9 (16.9); Time Post-injury = 125.6 (128.8) days; traumatic and non-traumatic brain injury; Korean sample

Level of test-retest agreement was very high (97.4%; 38 of 39 cases)

Iazeva, 2018; n = 58; Median Age = 46 (18); Mean Time Post-injury = 2.5 (1) months; traumatic and non-traumatic brain injury; Russian sample

Test-retest consistency was high with the correlation coefficient r=1 (р<.0001), indicating the stability of patient’s assessment during a short observation period over one day

La Porta, 2013; n = 129; Mean Age = 47 (20); Mean Time Post-injury = 421 (599) days; traumatic and non-traumatic brain injury; Italian sample

CRS-R Test-Retest Reliability by Paper

	Giacino and Kalmar (2004)			Schnakers et al (2008)
Study design and setting
No. of centers	1			5
Assessment setting	R			A, R,
Sample size	80			77
No. of raters	2			24
Sample size/rater ratio	40			3.2
Reliability	IRR	TRT	ICR	IRR	TRT	ICR
Auditory subscale	K=.86	K = 0.63 ^t		K= .82*
Visual subscale	K= .58^t	K=0.90		K=.85
Motor subscale	K= . 78*	K= 1.00		K=.93
Oromotor subscale	K= .77*	K= 0.23^t		K=.92
Communication subscale	K=.88	K=0.89		K=.98
Vigilance subscale	NA	NA		K= . 74*
Total score	p= .84 *	p=0.94	a= .84*	K= .8 0*	NA	NA

	Lovstad et al (2010)			Simoes et al (2011)			Sacco et al (2011)
Study design and setting
No. of centers	6			1			1
Assessment setting	R			A			R
Sample size	31			20			38
No. of raters	8			2			2
Sample size/rater ratio	3.8			10			19
Reliability	IRR	TRT	ICR	IRR	TRT	ICR	IRR	TRT	ICR
Auditory subscale	K=.90	K= . 71*		ICC=0.99	ICC= .86		Kw = . 6St	Kw = 0.80*
Visual subscale	K= .46^t	K=.86		ICC=l.00	ICC= .88		Kw = . 71*	Kw = 0.84*
Motor subscale	K= .67^t	K= .73*		ICC=0.98	ICC=.81*		Kw = . 79*	Kw = 0.96
Oromotor subscale	K=.89	K= . 71*		ICC=0.96	ICC= .82*		Kw = .44t	Kw = 0.8 5
Communication subscale	K= .62^t	K=.89		ICC=0.97	ICC= .82*		Kw = .88	Kw = 0.88
Vigilance subscale	NA	NA		ICC=0.98	ICC= .84*		Kw = .51t	Kw = l. 00
Total score	K=.94	NA	a= .74*	ICC=0.99	ICC= .87	NA	p= .81 *	p=0.97	a= .81 *

NOTE. Where several reliability values were available, we reported only the largest ones. Comparison of the various studies may be difficult in view of the fact that the classical psychometric properties reported are strictly sample-dependent and several reliability coefficients were used across different studies.

Abbreviations: a, Cronbach alpha; A, acute setting; CRS-R, CRS-R total score; ICC, intraclass correlation coefficient; ICR, internal consistency reliability; IRR, interrater reliability; K, Cohen Kappa; Kw, weighted Kappa; NA, not applicable; p, Spearman correlation coefficient; R, rehabilitation setting; TRT, test-retest reliability.

* Values compatible only with measurement at the group level (≥ .70 <.85), not at the individual level (≥ .85 ).

t Values not sufficiently reliable for any measurement (< . 70), including measurement at the group level.

Lovstad, 2010; n = 31; Mean Age = 33 (15); Median Time Post-injury = 143, range = 21–2130 days; traumatic and non-traumatic brain injury; Norwegian sample

Test-retest reliability for rater A from day 2 to 3 was very good (ρ = 0.83) and good for rater C from day 1 to 3 (ρ = 0.77)
Test-retest agreement was very good for rater A from day 2 to 3 (ICC = 0.87, 95% CI 0.75–0.94) and good for rater C from day 1 to 3 (ICC = 0.78, 95% CI 0.58–0.90)
Test-retest agreement from days 1 to 3 was also higher for the moderately experienced raters versus newly trained raters
Test-retest correlations within the newly trained rater group were not significant (ρ = 0.15 and P = .09)

	Experienced Rater A Day 2 and 3	Less-experienced Rater C Day 1 and 3
	Spearman	Cohen’s kappa	Spearman	Cohen’s kappa
Auditory	0.84	0.71	0.33	0.35
Visual	0.80	0.86	0.74	0.57
Motor	0.85	0.73	0.59	0.81
Oromotor	0.90	0.71	0.86	0.87
Communication	0.90	0.89	0.91	0.89
Arousal	0.59	NA	0.70	NA

Zhang, 2010; n = 169; Median Age = 58, range = 18–86; Time Post-injury: range = 70-99; traumatic and non-traumatic brain injury; Chinese sample

Good test-retest reliability for CRS-R total score and subscale scores (intra-class correlation coefficient [ICC] = 0.87 and ICC = 0.66-0.84, respectively)

Interrater/Intrarater Reliability

Binder, 2018; n = 20; Median Age = 38.0 (14.39); Mean Time Post-TBI = 1.5 (0.5) days; severe TBI; Polish sample

Inter-rater reliability for CRS-R total scores was excellent: (ρ = 0.76, p < 0.001). Inter-rater reliability for subscales was fair to excellent

Estraneo, 2015; n = 122; Mean Age = 54.58, range = 14-88; Time Post-injury = 25 - >365 days; traumatic or non-traumatic brain injury; Italian population

Italian version of CRS-R has good-to-excellent interrater reliability for all subscales, particularly Communication (k=1)

Inter-rater agreement on single subscales of CRS-R, and on diagnostic classification based on CRS-R, expressed as Fleiss generalized Kappa statistic (and 95% Confidence Interval)

Subscale	All Raters (N =27)
Auditory	0.76 (0.66 – 0.83)
Visual	0.73 (0.63 – 0.81)
Motor	0.76 (0.66 – 0.83)
Oromotor	0.73 (0.63 – 0.81)
Communication	1
Arousal	0.72 (0.63 – 0.80)
Diagnostic Classification	0.79 (0.71 – 0.84)

Italian version of the CRS-R demonstrated high sensitivity (indicating proportion of subjects diagnosed as VS by CRS-R: 91.9%, 95% CI: 82.4-96.5)
Also demonstrated high specificity (indicating proportion of subjects diagnosed as not VS by CRS-R: 86.7%, 95% CI: 82.4-96.5)

Interrater Reliability of Dichotomized CRS-R Subscale Scores (n=20)
Subscale	Cohen kappa	95% CI	P	Rater Agreement
Auditory	.86	±.27	.01	95%
Visual	.58	±.33	.03	80%
Motor	.78	±.28	.01	90%
Oromotor/Verbal	.77	±.42	.03	95%
Communication	.88	±.24	.00	95%

Han, 2018; n = 39; Mean Age = 56.9 (16.9); Time Post-injury = 125.6 (128.8) days; traumatic and non-traumatic brain injury; Korean sample

Inter-rater reliability (k=0.929, p<0.01) and intra-rater reliability (k=0.938, p<0.01) were both high for total K-CRSR scores
Inter- and intra-rater agreement rates were very high (94.9% and 97.4%, respectively)
Inter-rater reliability of the total score for K-CRSR and its subscales was very high (Ƙ=0.93, p<0.01)—motor (Ƙ=0.84, p<0.01), oromotor/verbal (Ƙ=0.90, p<0.01), communication (Ƙ=1.00, p<0.01), arousal (Ƙ=0.90, p<0.01), auditory (Ƙ=0.95, p<0.01), visual (Ƙ=0.86, p<0.01)
Agreement between the scores of rater B on day 1 and the scores of rater A on day 3 was very high (Ƙ=0.908, p<0.01)—motor (Ƙ=0.84, p<0.01), oromotor/verbal (Ƙ=0.91, p<0.01), communication (Ƙ=1.00, p<0.01), arousal (Ƙ=0.85, p<0.01), auditory (Ƙ=0.95, p<0.01), visual (Ƙ=0.90, p<0.01)
intra-rater reliability of the total score for K-CRSR and its subscales was very high (Ƙ=0.94, p<0.01)—motor (Ƙ=0.84, p<0.01), oromotor/verbal (Ƙ=0.95, p<0.01), communication (Ƙ=1.00, p<0.01), arousal (Ƙ=0.95, p<0.01), auditory (Ƙ=0.95, p<0.01), visual (Ƙ=0.91, p<0.01)
Reliability was in perfect agreement with the score for the communication subscale

Iazeva, 2018; n = 58; Median Age = 46 (18); Mean Time Post-injury = 2.5 (1) months; traumatic and non-traumatic brain injury; Russian sample

Inter-rater reliability for the CRS-R total score (κ=0.99, p<0.001) and subscale scores was good

Subscales	Cohen’s kappa	95% Confidence Interval		p for Cohen’s kappa
Total Score	0.99	0.876	1.0	<0.001
Auditory	0.934	0.848	1.0	<0.001
Visual	0.873	0.763	0.957	<0.001
Motor	0.979	0.919	1,0	<0.001
Oromotor	0.961	0.854	1,0	<0.001
Communication	1.0	1.0	1.0	<0.001
Arousal	1.0	1.0	1.0	<0.001

La Porta, 2013; n = 129; Mean Age = 47 (20); Mean Time Post-injury = 421 (599) days; traumatic and non-traumatic brain injury; Italian sample

Summary table of CRS-R reliability studies through 2011

Summary of reliability study results of the CRS-R, adapted from La Porta (2013)

Giacino and Kalmar (2004) Schnakers et al (2008) Lovstad et al (2010) Simoes et al (2011)

Sacco et al (2011)

Study design and setting

No. of centers

Assessment setting

A, R, NH

R, NH

Sample size

No. of raters

Sample size/rater ratio

3.2

3.8

Reliability

IRR

TRT

ICR

IRR

TRT

ICR

IRR

TRT

ICR

IRR

TRT

ICR

IRR

TRT ICR

Auditory subscale

K=.86

K = 0.63 ^t

K= .82*

K=.90

K= . 71*

ICC=0.99

ICC= .86

Kw = . 6St

Kw = 0.80*

Visual subscale

K= .58^t

K=0.90

K=.85

K= .46^t

K=.86

ICC=l.00

ICC= .88

Kw = . 71*

Kw = 0.84*

Motor subscale

K= . 78*

K= 1.00

K=.93

K= .67^t

K= .73*

ICC=0.98

ICC=.81*

Kw = . 79*

Kw = 0.96

Oromotor subscale

K= .77*

K= 0.23^t

K=.92

K=.89

K= . 71*

ICC=0.96

ICC= .82*

Kw = .44t

Kw = Q.8 5

Communication subscale

K=.88

K=0.89

K=.98

K= .62^t

K=.89

ICC=0.97

ICC= .82*

Kw = .88

Kw = 0.88

Vigilance subscale

K= . 74*

ICC=0.98

ICC= .84*

Kw = .51t

Kw = l. QQ

Total score

p= .84 *

p=0.94

a= .84*

K= .8 0*

K=.94

a= .74*

ICC=0.99

ICC= .87

p= .81 *

p=0.97 a= .81 *

Abbreviations: a, Cronbach alpha; A, acute setting; CRS-R, CRS-R total score; ICC, intraclass correlation coefficient; ICR, internal consistency reliability; IRR, interrater reliability; K, Cohen Kappa; Kw, weighted Kappa; NA, not applicable; p, Spearman correlation coefficient; R, rehabilitation setting; TRT, test-retest reliability.

* Values compatible only with measurement at the group level (≥ .70 <.85), not at the individual level (≥ .85 ).

^t Values not sufficiently reliable for any measurement (< . 70), includinq measurement at the qroup level.

Lovstad, 2010; n = 31; Mean Age = 33 (15); Median Time Post-injury = 143, range = 21–2130 days; traumatic and non-traumatic brain injury; Norwegian sample

Good interrater agreement between the experienced

rater (ρ =0.77)

Interrater correlations within the newly trained rater group were not significant (ρ = 0.15 and P = .09)
Interrater agreement was not affected by whether a rater had prior exposure (ρ = 0.68, P = .01, n = 16) or no prior exposure (ρ = 0.67, P = .03, n = 12)

Portaccio, 2018a; n = 110; Mean Age = 58.7 (16.2); Time Post-injury = 2.1 (2.1) months; traumatic and non-traumatic brain injury; Italian sample

Across 6 raters, Kappa coefficient for total scores yielded a rate of agreement of 0.827

Schnakers, 2008b; n = 77; traumatic brain injury; French-speaking sample

Inter-rater reliability for the CRS-R total score was good (k= 0.80).
Mean kappa values:
- good to excellent for the auditory (k= 0.82),
- visual (k= 0.85), motor (k= 0.93),
- oromotor (k= 0.92),
- communication (k=0.98) and
- arousal (k=0.74) sub-scales

Slomine, 2019; n=33; Age range: 8-59 months; typically developing children

Inter-rater reliability of the Coma Recovery Scale for Pediatrics (CRS-P) subscale scores was adequate (Kw = .87–1.00)

Tamashiro, 2014; n = 35; severe acquired brain injury; Spanish-speaking sample

Inter-rater reliability was good for total CRS-R scores (Cronbach α = 0.973, p = 0.001).
Sub-scale analysis showed moderate-to-high inter-rater agreement

Zhang, 2010; n = 169; Median Age = 58, range = 18–86; Time Post-injury: range = 70-99; traumatic and non-traumatic brain injury; Chinese sample

Inter-rater reliability was high (ICC = 0.719; p < 0.01)

Internal Consistency

Binder, 2018; n = 20; Median Age = 38.0 (14.39); Mean Time Post-TBI = 1.5 (0.5) days; severe TBI; Polish sample

Internal consistency was excellent (Cronbach’s α = 0.85)

Relationship between CRS-R total score and the individual subscale scores was investigated using Cronbach α. Resulted in an α value of .83, indicating that CRS-R has excellent internal consistency

CRS-R Subscale Intercorrelations (N=80)
Subscale	Auditory	Visual	Motor	Oromotor/ Verbal	Communication	Arousal
Auditory	1.00
Visual	0.70	1.00
Motor	0.60	0.60	1.00
Oromotor/ Verbal	0.51	0.29	0.47	1.00
Communication	0.62	0.54	0.49	0.65	1.00
Arousal	0.50	0.43	0.31	0.44	0.63	1.00

Han, 2018; n = 39; Mean Age = 56.9 (16.9); Mean Time Post-injury = 125.6 (128.8) days; traumatic and non-traumatic brain injury; Korean sample

Cronbach’s alpha showed a high degree of internal consistency. Specifically, it was 0.9 for rater A on day 1, 0.9 for rater B and 0.9 for rater A on day 3

Iazeva, 2018; n = 58; Median Age = 46 (18); Mean Time Post-injury = 2.5 (1) months; traumatic and non-traumatic brain injury; Russian sample

Internal consistency of the total score using Cronbach’s alpha was high 0.87 (p=0.0001). More precisely, α=0.87 and 0.89 for the first and second visit respectively

La Porta, 2013; n = 129; Mean Age = 47 (20); Mean Time Post-injury = 421 (599) days; traumatic and non-traumatic brain injury; Italian sample

Rasch Analysis demonstrated excellent internal consistency (Cronbach’s alpha= .83, as per Giacino et al., 2004)

Lovstad, 2010; n = 31; Mean Age = 33 (15); Median Time Post-injury = 143, range = 21–2130 days; traumatic and non-traumatic brain injury; Norwegian sample

Good to Excellent: Cronbach’s α for each of the 5 assessments ranged from 0.68 to 0.85, with a mean of 0.74, and corresponding 95% CI [0.6–0.9]

Zhang, 2010; n = 169; Median Age = 58, range = 18–86; Time Post-injury: range = 70-99; traumatic and non-traumatic brain injury; Chinese sample

Internal consistency for the total score was excellent (Cronbach's α = 0.84)

Criterion Validity (Predictive/Concurrent)

Concurrent

Casarotto, 2016; n = 150; Age range = 18–80 years; Median Time Post-TBI = 4 (1-7) days; traumatic or non-traumatic brain injury; Italian sample)

The Perturbation Complexity Index, derived by analyzing Transcranial Magnetic Resonance- evoked EEG signal has a sensitivity of 94.7% for detecting MCS patients on the CRS-R.

Di Perri, 2016; n = 58; Age Range = 11-82; Time Post-injury = All more than 28 days; traumatic or non-traumatic brain injury; French-speaking sample

Positive functional magnetic resonance imaging (fMRI) default mode network connectivity correlated with CRS-R scores

Estraneo, 2015; n = 122; Mean Age = 54.58, range = 14-88; Time Post-injury = 25 - >365 days; traumatic or non-traumatic brain injury; Italian population

Italian version of CRS-R shows high sensitivity (indicating proportion of subjects designated as VS by the CRS-R: 91.9%, 95% CI: 82.4-96.5) and high specificity (indicating proportion of subjects designated as not VS by CRS-R: 86.7%, 95% CI: 82.4-96.5) with reference to clinical consensus diagnosis
Good concurrent validity between CRS-R and DRS. Spearman correlation coefficients between CRS-R and DRS significant for total sample (p < 0.001)

CRS-R total scores correlated significantly with total scores on the CRS and DRS indicating acceptable concurrent validity
Spearman coefficients were significant between the CRS-R and the CRS (ρ=.97, P<.001) and between the CRS-R and DRS (ρ=−.90, P<.001)

Han, 2018; n = 39; Mean Age = 56.9 (16.9); Time Post-injury = 125.6 (128.8) days; traumatic and non-traumatic brain injury; Korean sample

Total score for the Korean CRSR (K-CRSR) was strongly correlated with the total score for K-GCS, and the Spearman correlation coefficient was significant (r=0.894, p<0.01)

Iazeva, 2018; n = 58; Median Age = 46 (18); Mean Time Post-injury = 2.5 (1) months; traumatic and non-traumatic brain injury; Russian sample

CRS-R showed good criterion validity between two other standardized behavioral scales (adequate correlation with GCS, r=0.597 and excellent correlation with FOUR Score, r=0.900)
CRS-R demonstrated a significantly higher sensitivity in differential diagnosis of DOC, as compared to GCS, and FOUR Score (p<0.001)
All selected CRS-R subscales showed significant (p<0.05) very high, high or moderate correlation with similar items on the other scales, except for visual function on the GCS (r= 0.257; p<0.05), where the correlation was significant but poor
Chi-squared analysis showed that the proportion of patients diagnosed with MCS by the CRS-R was significantly higher as compared to the GCS (χ2 =25; p<0.0001)

Schnakers, 2008b; n = 77; traumatic brain injury; French-speaking sample

Excellent concurrent validity between CRS-R and GCS, FOUR and WHIM in acute and between CRS-R and FOUR and WHIM in chronic patients.
The French version of the CRS-R demonstrated significantly higher sensitivity in detecting MCS patients, as compared to the GCS, FOUR & the WHIM

CSR-R	GCS	FOUR	WHIM
Both Stages	.59	.63	.76
Acute Stage	.72	.61	.68
Chronic Stage	.46	.69	.87

Lovstad, 2010; n = 31; Mean Age = 33 (15); Median Time Post-injury = 143, range = 21–2130 days; traumatic and non-traumatic brain injury; Norwegian sample

CRS-R sensitivity, which indicates the proportion of persons diagnosed as VS on the DRS that were also classified as VS on the CRS-R, was 0.54- 0 0.62.
CRS-R Specificity, which indicates the proportion of persons classified as not being in VS by the CRS-R or by the DRS, was 0.89-1.0 for the same experienced raters (see Table 5). The high specificity values indicate that those classified as in an MCS by the DRS are also categorized as MCS by the CRS-R. The rather low sensitivity values reflect that the CRS-R detected signs of consciousness (ie, MCS) while the DRS failed to do so.

Stender, 2014; n = 126; traumatic and non-traumatic brain injury; French-speaking sample

F-FDG PET had high sensitivity for identification of patients in a minimally conscious state (93%, 95% CI 85–98) and high congruence (85%, 77–90) with behavioral CRS–R scores

Tan, 2019; n = 22; Mean Age = 52, range = 16–72; Time Post-injury: range = 1.5-8 months; traumatic and non-traumatic brain injury; Chinese sample

Structural MRI findings correlate with CRS-R total score and DoC diagnosis

Tamashiro, 2014; n = 35; severe acquired brain injury; Spanish-speaking sample

Total CRS-R scores correlated significantly (p < 0.05) with total GCS (r = 0.74) and DRS (r = 0.54) scores, indicating acceptable concurrent validity

Zhang, 2010; n = 169; Median Age = 58, range = 18–86; Time Post-injury: range = 70-99; traumatic and non-traumatic brain injury; Chinese sample

Concurrent validity was good between CRS-R total scale and GCS total scale
Diagnostic validity was excellent compared with GCS (emerged from UWS: 24%; emerged from MCS: 28%)

Predictive

Coleman, 2007; n = 14; Age Range = 22-67; Time Post-injury = 2-122 months; traumatic or non-traumatic brain injury

Patients who responded to complex language stimuli during functional magnetic resonance imaging (fMRI) had higher CRS-R scores at 6-month follow-up

Giacino 2019; n= 97; Mean Age = 37.2 (15.4); Median time post injury = 47 days (37–65); traumatic brain injury

The odds of recovering a specific target behavior were 3.2 (95% CI: 1.2–8.1) to 7.8 (95% CI: 2.7–23.0) times higher for patients in MCS than for those in VS. Patients with preserved language function (MCS+) recovered the most behaviors (p ≤ 0.002) and had the least disability (p ≤ 0.002) at follow-up.

Hamilton, 2018; n = 70; Age Range = 19-69; Time Post-injury = 135.33 (76.02) days; traumatic and non-traumatic brain injury)

At week three of inpatient rehabilitation, the CRS-R scores of greater than or equal to 9 predicted emergence from MCS in an average of 72.9% of veterans

Lucca, 2019; n = 180; Mean Age = 51.43 (range: 33.7-72.3); Mean Time Post-injury = 6.8 (2.0) weeks; traumatic and non-traumatic brain injury; Italian sample

CRS-R diagnosis, CRS-R total scores and etiology were significantly associated with emergence from MCS

Portaccio, 2018a and 2018b; n = 110; Mean Age = 58.7 (16.2); Time Post-injury = 2.1 (2.1) months; traumatic and non-traumatic brain injury; Italian sample

Patients who transitioned from VS to MCS/eMCS or MCS to eMCS by rehabilitation discharge had higher score on the CRS-R at admission (9.7 ± 6.0 vs 7.5 ± 4.8, P < .047)
A higher CRS-R change score by week 4 of inpatient rehabilitation predicted likelihood of transition from VS to MCS/eMCS or MCS to eMCS

Construct Validity

Gerrard, 2014; n = 180; Mean Age = 36.6 (15.4); Time Post-injury = 4-16 weeks; TBI patients)

CRS-R shows evidence of construct validity and empirical support for the theoretical hierarchy of behaviors assessed within each subscale

Variety of Diagnoses affecting consciousness: (Schnakers et al., 2009, n=103 prospective patients with variety of diagnoses affecting consciousness, 55 (19) years, Belgian sample. Consensus medical diagnoses for vegetative, minimally conscious or “uncertain” were compared with diagnostic categories derived from CRS-R testing. )

Of 44 patients diagnosed in VS, 18 were in MCS; of 41 in MCS, 4 had emerged from MCS, and majority of “uncertain” diagnoses were in MCS (89%). The use of the CRS-R standardizes assessment and identified misclassified patients who have greater levels of consciousness than recognized by medical consensus.

Content Validity

Content validity assessment established a strong relationship between the CRS-R and the GCS, and moderate correlation between the CRS-R and the FOUR
Met all criteria of the Aspen workgroup definitions for MCS (Giacino 2002)

Thibaut, 2019; n=120; Mean Age = 47 ± 19 years; time post-injury: 40 ± 23 days; traumatic and non-traumatic injury

MCS patients with no behavioral evidence of language function (i.e., MCS-) were more functionally impaired than patients with behavioral evidence of language function (MCS+) at time of transition from VS and at discharge from inpatients rehabilitation.
Provides diagnostic criteria for MCS+ and MCS-

Floor/Ceiling Effects

The measure was designed to assess patients at Rancho Levels of Cognitive Functioning I-IV, so patients who are beyond these levels are not appropriate for its use.

Majority of CRS-R total scores fell in the middle range, demonstrating that the scale is not subject to ceiling or floor effects

La Porta, 2013; n = 129; Mean Age = 47 (20); Mean Time Post-injury = 421 (599) days; traumatic and non-traumatic brain injury; Italian sample

Rasch analysis revealed negligible floor and ceiling effects

Slomine, 2019; n=33; Age range: 8-59 months; typically developing children

All 4-year-olds, 75% of 3-year-olds, 10% of 2-year-olds, and 0% <2 years scored at the CRS-P ceiling.

Responsiveness

Giacino, 2012; n=; Mean Age = 35.5 (15); Median Time post- injury = 48 (380=-66); traumatic brain injury

patients who received amantadine had a higher rate of recovery across the six behaviors at the highest end of each CRS-R subscale.
after washout, behavioral recovery remained more favorable in the amantadine group across five of the six behaviors monitored.

Iazeva, 2018; n = 58; Median Age = 46 (18); Mean Time Post-injury = 2.5 (1) months; traumatic and non-traumatic brain injury; Russian sample

Median CRS-R total score after the first visit was 8.5 [5.0; 14.75] and after the second visit was 10.0 [5.0; 17.75], р<0.0001. In 11 patients (18,3%), this change was associated with a change in clinical diagnosis, suggesting sufficient sensitivity in capturing changes in diagnosis

Schiff, 2009; n=1; Age = 38; Time post injury = 6 years; traumatic brain injury

In a case-study, a patient showed the first instances of functional object use on the Motor subscale (score = 6) and intelligible verbalization on the Oromotor subscale (score = 3) after deep brain stimulation to the central thalamus. No previous episodes of intelligible verbalization had been observed during a series of 33 evaluations conducted across the 6 months of observation preceding the impact

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