- Email: [email protected]
Poster 45 Utility of the Coma Recovery Scale-Revised Total Score in Detecting Conscious Awareness
S106
Abstracts / PM R 7 (2015) S83-S222
independent in most activities but by the time of presentation, he reported about 15 falls every 6 months, interfering with his functional independence. Spine MRI showed a thoracic spinal cyst extending from T1-T2 to T9-T10 and measuring 3.3cm transversely 1.9cm anteroposteriorly. He underwent T3-T8 osteoplastic laminectomy, T2 laminectomy, and removal of spinal cyst without major complications. Surgical pathology confirmed the diagnosis of spinal arachnoid cyst. Setting: Academic Tertiary Care Hospital. Results or Clinical Course: After medical optimization, the patient was admitted to inpatient rehabilitation on post-operative day seven. He underwent intensive multidisciplinary therapies, resulting in significant functional improvements in standing balance, activity tolerance, and ambulation. At the time of admission to inpatient rehabilitation, bilateral lower extremity strength was 3/5 diffusely and Timed Up and Go (TUG) was 36 seconds. This prolonged TUG score predicts dependence in ADLs and mobility. By the time of discharge back to Panama, bilateral lower extremity strength increased to 4/5 in hip and knee flexors, he was ambulating 300 feet without an assistive device, and TUG improved to 16 seconds. Discussion: This is the first reported case of a patient with AxenfeldRieger syndrome with a symptomatic spinal arachnoid cyst who experienced significant functional improvement after surgical excision of the cyst and intensive inpatient rehabilitation. According to the available literature, early surgical intervention for spinal arachnoid cysts is recommended and generally results in better outcomes. Conclusion: Despite relatively delayed diagnosis and intervention, as well as underlying physical impairments, life-altering improvements in function and independence are possible for motivated patients with spinal arachnoid cysts after excision and intensive rehabilitation.
Poster 44 An Empirical Classification Scheme for Detection of Impossible and Improbable CRS-R Subscore Combinations Camille Chatelle, PhD, Yelena Bodien, PhD (Spaulding Rehabilitation Hospital, Charlestown, MA, United States), Cecilia Carlowicz, BSc, Steven Laureys, MD, PhD, Joseph T. Giacino, PhD Disclosures: Y. Bodien: I Have No Relevant Financial Relationships To Disclose. Objective: The Coma Recovery Scale-Revised (CRS-R) is a standardized neurobehavioral measure designed for use in diagnostic and prognostic assessment in patients with disorders of consciousness (DOC). The aims of this study are to determine the probability with which specific CRS-R subscale score combinations occur and to provide clinicians and researchers with a method of determining impossible or improbable scores. Design: Retrospective data analysis from three databases including patients admitted to hospitals in the United States and Belgium. Setting: Specialized inpatient DOC Program and university hospitals. Participants: 869 patients diagnosed with DOC (569 male, mean age ¼ 47, standard deviation¼20, time since insult¼ 240815 days). Interventions: Not applicable Main Outcome Measures: Impossible score combinations were defined as two scores that cannot co-occur based on standard scoring guidelines. To determine improbable score combinations, we calculated the Mahalanobis distance for each pair of subscores (e.g., visual subscore of 1 and motor subscore of 2) and conducted a chi square analysis to determine the P value associated with the distance of each pair from the centroid. We then classified score combinations as “improbable” (P<.05) and “very improbable” (P<.02). Results or Clinical Course: Of the 869 CRS-R profiles analyzed, 8.5% were excluded because they met impossible scoring criteria. Among the 796 remaining profiles, 7% (24/330) of subscale score pairs were classified as improbable and 18% (60/330) very improbable (e.g., functional object use co-occurring with auditory startle).
Conclusion: An empirically-derived classification scheme can be used to determine the validity and probability of CRS-R subscore combinations. This methodology can be applied in data quality analysis and may have diagnostic utility in clinical practice.
Poster 45 Utility of the Coma Recovery Scale-Revised Total Score in Detecting Conscious Awareness Yelena Bodien, PhD (Spaulding Rehabilitation Hospital, Charlestown, MA, United States), Cecilia Carlowicz, BSc, Camille Chatelle, PhD, Joseph T. Giacino, PhD Disclosures: Y. Bodien: I Have No Relevant Financial Relationships To Disclose. Objective: The Coma Recovery Scale-Revised (CRS-R) is a standardized neurobehavioral assessment measure designed for use in differential diagnosis, prognostic assessment, and treatment planning in patients with disorders of consciousness. Twenty-three items are divided into 6 subscales that assess auditory, visual, motor, oromotor, communication and arousal functions. Despite the CRS-R’s clear criteria for establishing a diagnosis based on subscale scores, many research studies report only the total CRS-R score when discussing patient outcomes and clinicians frequently only consider total score improvements or declines when discussing recovery. The aim of this report is to describe the sensitivity and specificity of CRS-R total scores in detecting conscious awareness. Design: CRS-R scores were retrospectively extracted from the medical record of patients enrolled in the Spaulding Rehabilitation Network Disorders of Consciousness (DOC) program. Sensitivity and specificity analyses were completed with “conscious awareness” (i.e. CRS-Rderived diagnosis of minimally conscious state [MCS] or emerged from MCS) as the condition of interest and total CRS-R score as the “test criterion”. Setting: Specialized DOC Program. Participants: 253 inpatients (157 male, mean age ¼ 49, standard deviation¼19.7; mean days since injury¼48, standard deviation¼53; traumatic brain injury¼127, non-traumatic brain injury¼125). Interventions: NA Main Outcome Measures: Sensitivity and specificity of CRS-R total scores in detecting conscious awareness. Results or Clinical Course: A CRS-R total score of 10/23 provided 100% sensitivity for detecting conscious awareness, but only 64.2% specificity. That is, all patients with a total score of 10/23 or higher demonstrated conscious awareness, and 35.8% of patients scoring less than 10/23 also demonstrated conscious awareness. A total score of 7/ 23 yielded optimal sensitivity (90.4%) and specificity (90.3%). Conclusion: Examiners should be aware that CRS-R total score cutoffs are associated with marked differences in sensitivity and specificity relative to detection of conscious awareness.
Poster 46 Impact of Earlier Rehabilitation on Outcomes Following Spinal Cord Injury Kurt Herzer, MSc (Johns Hopkins School of Medicine, Baltimore, MD, United States), Marlı´s Gonza´lez Ferna´ndez, MD, PhD Disclosures: K. Herzer: I Have No Relevant Financial Relationships To Disclose. Objective: To evaluate whether earlier rehabilitation improves outcomes following traumatic spinal cord injury (SCI). Design: Retrospective observational study. Inverse-probability weighting (IPW) with propensity scores was used to estimate average treatment effects and reduce confounding. Setting: Acute and post-acute care provided in 6 specialized SCI rehabilitation programs in the United States between 2007 and 2009.
Abstracts / PM R 7 (2015) S83-S222
independent in most activities but by the time of presentation, he reported about 15 falls every 6 months, interfering with his functional independence. Spine MRI showed a thoracic spinal cyst extending from T1-T2 to T9-T10 and measuring 3.3cm transversely 1.9cm anteroposteriorly. He underwent T3-T8 osteoplastic laminectomy, T2 laminectomy, and removal of spinal cyst without major complications. Surgical pathology confirmed the diagnosis of spinal arachnoid cyst. Setting: Academic Tertiary Care Hospital. Results or Clinical Course: After medical optimization, the patient was admitted to inpatient rehabilitation on post-operative day seven. He underwent intensive multidisciplinary therapies, resulting in significant functional improvements in standing balance, activity tolerance, and ambulation. At the time of admission to inpatient rehabilitation, bilateral lower extremity strength was 3/5 diffusely and Timed Up and Go (TUG) was 36 seconds. This prolonged TUG score predicts dependence in ADLs and mobility. By the time of discharge back to Panama, bilateral lower extremity strength increased to 4/5 in hip and knee flexors, he was ambulating 300 feet without an assistive device, and TUG improved to 16 seconds. Discussion: This is the first reported case of a patient with AxenfeldRieger syndrome with a symptomatic spinal arachnoid cyst who experienced significant functional improvement after surgical excision of the cyst and intensive inpatient rehabilitation. According to the available literature, early surgical intervention for spinal arachnoid cysts is recommended and generally results in better outcomes. Conclusion: Despite relatively delayed diagnosis and intervention, as well as underlying physical impairments, life-altering improvements in function and independence are possible for motivated patients with spinal arachnoid cysts after excision and intensive rehabilitation.
Poster 44 An Empirical Classification Scheme for Detection of Impossible and Improbable CRS-R Subscore Combinations Camille Chatelle, PhD, Yelena Bodien, PhD (Spaulding Rehabilitation Hospital, Charlestown, MA, United States), Cecilia Carlowicz, BSc, Steven Laureys, MD, PhD, Joseph T. Giacino, PhD Disclosures: Y. Bodien: I Have No Relevant Financial Relationships To Disclose. Objective: The Coma Recovery Scale-Revised (CRS-R) is a standardized neurobehavioral measure designed for use in diagnostic and prognostic assessment in patients with disorders of consciousness (DOC). The aims of this study are to determine the probability with which specific CRS-R subscale score combinations occur and to provide clinicians and researchers with a method of determining impossible or improbable scores. Design: Retrospective data analysis from three databases including patients admitted to hospitals in the United States and Belgium. Setting: Specialized inpatient DOC Program and university hospitals. Participants: 869 patients diagnosed with DOC (569 male, mean age ¼ 47, standard deviation¼20, time since insult¼ 240815 days). Interventions: Not applicable Main Outcome Measures: Impossible score combinations were defined as two scores that cannot co-occur based on standard scoring guidelines. To determine improbable score combinations, we calculated the Mahalanobis distance for each pair of subscores (e.g., visual subscore of 1 and motor subscore of 2) and conducted a chi square analysis to determine the P value associated with the distance of each pair from the centroid. We then classified score combinations as “improbable” (P<.05) and “very improbable” (P<.02). Results or Clinical Course: Of the 869 CRS-R profiles analyzed, 8.5% were excluded because they met impossible scoring criteria. Among the 796 remaining profiles, 7% (24/330) of subscale score pairs were classified as improbable and 18% (60/330) very improbable (e.g., functional object use co-occurring with auditory startle).
Conclusion: An empirically-derived classification scheme can be used to determine the validity and probability of CRS-R subscore combinations. This methodology can be applied in data quality analysis and may have diagnostic utility in clinical practice.
Poster 45 Utility of the Coma Recovery Scale-Revised Total Score in Detecting Conscious Awareness Yelena Bodien, PhD (Spaulding Rehabilitation Hospital, Charlestown, MA, United States), Cecilia Carlowicz, BSc, Camille Chatelle, PhD, Joseph T. Giacino, PhD Disclosures: Y. Bodien: I Have No Relevant Financial Relationships To Disclose. Objective: The Coma Recovery Scale-Revised (CRS-R) is a standardized neurobehavioral assessment measure designed for use in differential diagnosis, prognostic assessment, and treatment planning in patients with disorders of consciousness. Twenty-three items are divided into 6 subscales that assess auditory, visual, motor, oromotor, communication and arousal functions. Despite the CRS-R’s clear criteria for establishing a diagnosis based on subscale scores, many research studies report only the total CRS-R score when discussing patient outcomes and clinicians frequently only consider total score improvements or declines when discussing recovery. The aim of this report is to describe the sensitivity and specificity of CRS-R total scores in detecting conscious awareness. Design: CRS-R scores were retrospectively extracted from the medical record of patients enrolled in the Spaulding Rehabilitation Network Disorders of Consciousness (DOC) program. Sensitivity and specificity analyses were completed with “conscious awareness” (i.e. CRS-Rderived diagnosis of minimally conscious state [MCS] or emerged from MCS) as the condition of interest and total CRS-R score as the “test criterion”. Setting: Specialized DOC Program. Participants: 253 inpatients (157 male, mean age ¼ 49, standard deviation¼19.7; mean days since injury¼48, standard deviation¼53; traumatic brain injury¼127, non-traumatic brain injury¼125). Interventions: NA Main Outcome Measures: Sensitivity and specificity of CRS-R total scores in detecting conscious awareness. Results or Clinical Course: A CRS-R total score of 10/23 provided 100% sensitivity for detecting conscious awareness, but only 64.2% specificity. That is, all patients with a total score of 10/23 or higher demonstrated conscious awareness, and 35.8% of patients scoring less than 10/23 also demonstrated conscious awareness. A total score of 7/ 23 yielded optimal sensitivity (90.4%) and specificity (90.3%). Conclusion: Examiners should be aware that CRS-R total score cutoffs are associated with marked differences in sensitivity and specificity relative to detection of conscious awareness.
Poster 46 Impact of Earlier Rehabilitation on Outcomes Following Spinal Cord Injury Kurt Herzer, MSc (Johns Hopkins School of Medicine, Baltimore, MD, United States), Marlı´s Gonza´lez Ferna´ndez, MD, PhD Disclosures: K. Herzer: I Have No Relevant Financial Relationships To Disclose. Objective: To evaluate whether earlier rehabilitation improves outcomes following traumatic spinal cord injury (SCI). Design: Retrospective observational study. Inverse-probability weighting (IPW) with propensity scores was used to estimate average treatment effects and reduce confounding. Setting: Acute and post-acute care provided in 6 specialized SCI rehabilitation programs in the United States between 2007 and 2009.