Clinical assessment of patients with chronic disorders of consciousness by different medical specialists

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Abstract

Introduction. Clinical assessment of consciousness in patients coming out of a coma remains a topic of discussion. Monitoring these patients over time is challenging not only because of the slow fluctuations in their neurological status, but also because doctors are not fully aware of the classification of chronic disorders of consciousness (CDC), and how to use the Coma Recovery Scale-revised (CRS-R), which was specifically developed for this group of patients. In practice, most doctors use standard neurological examination to assess consciousness rather than the CRS-R. We have hypothesized that this approach leads to contradictory and poorly standardized results.

Materials and methods. We investigated the level of inter-expert reliability in pairs of three medical specialists: neurologists, neurosurgeons and neurocritical care specialists (working in neurocritical care units) in the clinical assessment of consciousness. Their examination findings were compared to the CRS-R scores.

Results. The inter-expert reliability was poor in all three specializations when using clinical examination to determine the degree of impaired consciousness in patients with CDC. An average level of IER (Cohen's kappa = 0.46) was found only in the neurosurgeon–CRS-R pair.

Conclusion. A scale with detailed criteria is different to a standard clinical examination and has a higher level of IER. Moving from subjective evaluation to a standardized CRS-R will enable medical specialists to determine a patient’s rehabilitation potential and predict disease progression more accurately. Educational programmes, including virtual platforms, should be developed to encompass most of the medical community.

About the authors

Polina I. Solovyeva

Sklifosovsky Research Institute for Emergency Care

Author for correspondence.
Email: psolovyeva@yandex.ru
ORCID iD: 0000-0001-6858-6210

junior researcher, neurologist, Neurosurgical department

Russian Federation, 129010, Moscow, Bol’shaya Sukharevskaya square, 3

Mikhail V. Sinkin

Sklifosovsky Research Institute for Emergency Care; A.I. Evdokimov Moscow State Medicine and Dentistry University

Email: mvsinkin@gmail.com
ORCID iD: 0000-0001-5026-0060

Cand. Sci. (Med.), senior researcher, neurophysiology team leader, Neurosurgical department

Russian Federation, 129010, Moscow, Bol’shaya Sukharevskaya square, 3; Moscow

Alexander E. Talypov

Sklifosovsky Research Institute for Emergency Care

Email: psolovyeva@yandex.ru
ORCID iD: 0000-0002-6789-8164

D. Sci. (Med.), chief researcher, Neurosurgical department

Russian Federation, 129010, Moscow, Bol’shaya Sukharevskaya square, 3

Dilara I. Abzalova

Sklifosovsky Research Institute for Emergency Care

Email: psolovyeva@yandex.ru
ORCID iD: 0000-0002-7217-6940

junior researcher, neurologist, Neurosurgical department

Russian Federation, 129010, Moscow, Bol’shaya Sukharevskaya square, 3

Ganipa R. Ramazanov

Sklifosovsky Research Institute for Emergency Care

Email: psolovyeva@yandex.ru
ORCID iD: 0000-0001-6824-4114

Cand. Sci. (Med.), Head, Science division, Neurological department

Russian Federation, 129010, Moscow, Bol’shaya Sukharevskaya square, 3

Ester D. Mehia-Mehia

A.I. Evdokimov Moscow State Medicine and Dentistry University

Email: psolovyeva@yandex.ru

Head, Intensive care department

Russian Federation, Moscow

Evgeniy Yu. Bakharev

Sklifosovsky Research Institute for Emergency Care

Email: psolovyeva@yandex.ru
ORCID iD: 0000-0003-1525-1585

Cand. Sci. (Med.), neurosurgeon, Neurosurgical department

Russian Federation, 129010, Moscow, Bol’shaya Sukharevskaya square, 3

Konstantin A. Popugayev

Sklifosovsky Research Institute for Emergency Care; A.I. Burnazyan Medical and Biological University of Innovations and Continuing Education Federal Medical Biophysical Center

Email: psolovyeva@yandex.ru
ORCID iD: 0000-0002-6240-820X

D. Sci. (Med.), Professor, Deputy Director, Head, Regional Vascular Center, Head, Department of anesthesiology, resuscitation intensive care

Russian Federation, 129010, Moscow, Bol’shaya Sukharevskaya square, 3; Moscow

Andrey A. Grin

Sklifosovsky Research Institute for Emergency Care; A.I. Evdokimov Moscow State Medicine and Dentistry University

Email: psolovyeva@yandex.ru
ORCID iD: 0000-0003-3515-8329

D. Sci. (Med.), Professor, Chief neurosurgeon, Moscow Healthcare Department, Department of neurosurgery and neurocritical care, Head, Science division, Neurosurgical department

Russian Federation, 129010, Moscow, Bol’shaya Sukharevskaya square, 3; Moscow

References

  1. Owen A.M., Coleman M.R. Detecting awareness in the vegetative state. Ann. N. Y. Acad. Sci. 2008; 1129: 130–138. doi: 10.1196/annals.1417.018
  2. Xie Q., Ni X., Yu R,. et al. Chronic disorders of consciousness. Exp. Ther. Med. 2017; 14(2): 1277–1283. doi: 10.3892/etm.2017.4639
  3. Cruse D., Chennu S., Chatelle C. et al. Bedside detection of awareness in the vegetative state: a cohort study. Lancet. 2011; 378(9809): 2088–2094. doi: 10.1016/S0140-6736(11)61224-5
  4. Schnakers C., Vanhaudenhuyse A., Giacino J. et al. Diagnostic accuracy of the vegetative and minimally conscious state: clinical consensus versus standardized neurobehavioral assessment. BMC Neurol. 2009; 9: 35. doi: 10.1186/1471-2377-9-35
  5. Giacino J.T., Schnakers C., Rodriguez-Moreno D. et al. Behavioral assessment in patients with disorders of consciousness: gold standard or fool’s gold? Prog. Brain Res. 2009; 177: 33–48. doi: 10.1016/S0079-6123(09)17704-X
  6. Schnakers C., Giacino J., Kalmar K. et al. Does the FOUR score correctly diagnose the vegetative and minimally conscious states? Ann. Neurol. 2006; 60(6): 744–745; author reply 745. doi: 10.1002/ana.20919
  7. Schnakers C., Monti M.M. Towards improving care for disorders of consciousness. Nat. Rev. Neurol. 2020; 16(8): 405–406. doi: 10.1038/s41582-020-0358-y
  8. Wade D. Back to the bedside? Making clinical decisions in patients with prolonged unconsciousness. J. Med. Ethics. 2017; 43(7): 457–458. doi: 10.1136/medethics-2015-103140
  9. Nachev P., Hacker P.M. Covert cognition in the persistent vegetative state. Prog. Neurobiol. 2010; 91(1): 68–76. doi: 10.1016/j.pneurobio.2010.01.009
  10. Mashour G.A., Avidan M.S. Capturing covert consciousness. Lancet. 2013; 381(9863): 271–272. doi: 10.1016/S0140-6736(13)60094-X
  11. Jennett B., Plum F. Persistent vegetative state after brain damage. A syndrome in search of a name. Lancet. 1972; 1(7753): 734–737. doi: 10.1016/s0140-6736(72)90242-5
  12. Plum F., Posner J.B. The diagnosis of stupor and coma. Contemp. Neurol. Ser. 1972; 10: 1–286.
  13. Multi-Society Task Force on PVS. Medical aspects of the persistent vegetative state (1). N. Engl. J. Med. 1994; 330(21): 1499–1508. doi: 10.1056/NEJM199405263302107
  14. Пирадов М.А., Супонева Н.А., Вознюк И.А. и др. Хронические нарушения сознания: терминология и диагностические критерии. Результаты первого заседания Российской рабочей группы по проблемам хронических нарушений сознания. Анналы клинической и экспериментальной неврологии. 2020; 14(1): 5–16. Piradov M.A., Suponeva N.A., Voznyuk I.A. et al. Chronic disorders of consciousness: terminology and diagnostic criteria. Results of the first meeting of the Russian working group on problems of chronic disorders of consciousness. Annals of clinical and experimental neurology. 2020; 14(1): 5–16. (In Russ.) doi: 10.25692/ACEN.2020.1.1
  15. Wade D.T. How often is the diagnosis of the permanent vegetative state incorrect? A review of the evidence. Eur. J. Neurol. 2018; 25(4): 619–625. doi: 10.1111/ene.13572
  16. Chaturvedi J., Mudgal S.K., Venkataram T. et al. Coma recovery scale: key clinical tool ignored enough in disorders of consciousness. Surg. Neurol. Int. 2021; 12: 93. doi: 10.25259/SNI_935_2020
  17. Iazeva E.G., Legostaeva L.A., Zimin A.A. et al. A Russian validation study of the Coma Recovery Scale-Revised (CRS-R). Brain Inj. 2019; 33(2): 218–225. doi: 10.1080/02699052.2018.1539248
  18. McHugh M.L. Interrater reliability: the kappa statistic. Biochem. Med. (Zagreb). 2012; 22(3): 276–282.
  19. Союз реабилитологов России. Нейропсихологическая диагностика и реабилитация пациентов с нарушениями сознания после повреждения головного мозга: методические рекомендации. М., 2019. 81 с. Union of Rehabilitologists of Russia. Neuropsychological diagnostics and rehabilitation of patients with impaired consciousness after brain damage: methodological recommendations. Moscow, 2019. 81 p. (In Russ.)
  20. Giacino J.T., Kalmar K., Whyte J. The JFK Coma Recovery Scale-Revised: measurement characteristics and diagnostic utility. Arch. Phys. Med. Rehabil. 2004; 85(12): 2020–2029. doi: 10.1016/j.apmr.2004.02.033
  21. American Congress of Rehabilitation Medicine, Brain Injury-Interdisciplinary Special Interest Group, Disorders of Consciousness Task Force et al. Assessment scales for disorders of consciousness: evidence-based recommendations for clinical practice and research. Arch. Phys. Med. Rehabil. 2010; 91(12): 1795–1813. doi: 10.1016/j.apmr.2010.07.218
  22. Binder M., Górska U., Wójcik-Krzemień A., Gociewicz K. A validation of the Polish version of the Coma Recovery Scale-Revised (CRSR). Brain Inj. 2018; 32(2): 242–246. doi: 10.1080/02699052.2017.1406991
  23. Schnakers C., Majerus S., Giacino J. et al. A French validation study of the Coma Recovery Scale-Revised (CRS-R). Brain Inj. 2008; 22(10): 786-792. doi: 10.1080/02699050802403557
  24. Mayer H., Nonn C., Osterbrink J., Evers G.C. Quality criteria of assessment scales--Cohen’s kappa as measure of interrator reliability (1). Pflege. 2004; 17(1): 36–46. (In German) doi: 10.1024/1012-5302.17.1.36

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Copyright (c) 2022 Solovyeva P.I., Sinkin M.V., Talypov A.E., Abzalova D.I., Ramazanov G.R., Mehia-Mehia E.D., Bakharev E.Y., Popugayev K.A., Grin A.A.

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