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THE ITALIAN/Lombardi 0,6 - Coma Science Group

From: CRS-R COMA RECOVERY scale -REVISED 2004 Joseph T. Giacino, and Kathleen Kalmar, Center for Head Injuries Edison, New Jersey italian version: Francesco lombardi , Giordano Gatta, Simona Sacco, Anna Muratori e Antonio Carolei Functional Neurology 2007;22(1):47-61. Francesco LombardiaGiordano GattabSimona Saccoc,dAnna MuratoriaAntonio CaroleicaDepartment of Intensive Neurorehabilitation, CorreggioHospital, Local Health Authority of Reggio Emilia, ItalybRehabilitation Medicine Unit, Ravenna Hospital, Raven-na, ItalycDepartment of Neurology, University of L Aquila, Italy dDepartment of Intensive Rehabilitation, San Raffaele In-stitute, Cassino, Italy Reprint requests to: Dr Francesco LombardiRiabilitazione Intensiva NeurologicaOspedale di Correggio42015 Correggio (RE) - ItalyE-mail: paperSummaryWe present, in the appendix, the italian version of theComa Recovery scale -Revised (CRS-R), a reliable toolthat can distinguish patients in the minimally con-scious state from those in a vegetative state.

From: CRS-R COMA RECOVERY SCALE-REVISED ©2004 Joseph T. Giacino, Ph.D. and Kathleen Kalmar, Ph.D. Center for Head Injuries Edison, New Jersey

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Transcription of THE ITALIAN/Lombardi 0,6 - Coma Science Group

1 From: CRS-R COMA RECOVERY scale -REVISED 2004 Joseph T. Giacino, and Kathleen Kalmar, Center for Head Injuries Edison, New Jersey italian version: Francesco lombardi , Giordano Gatta, Simona Sacco, Anna Muratori e Antonio Carolei Functional Neurology 2007;22(1):47-61. Francesco LombardiaGiordano GattabSimona Saccoc,dAnna MuratoriaAntonio CaroleicaDepartment of Intensive Neurorehabilitation, CorreggioHospital, Local Health Authority of Reggio Emilia, ItalybRehabilitation Medicine Unit, Ravenna Hospital, Raven-na, ItalycDepartment of Neurology, University of L Aquila, Italy dDepartment of Intensive Rehabilitation, San Raffaele In-stitute, Cassino, Italy Reprint requests to: Dr Francesco LombardiRiabilitazione Intensiva NeurologicaOspedale di Correggio42015 Correggio (RE) - ItalyE-mail: paperSummaryWe present, in the appendix, the italian version of theComa Recovery scale -Revised (CRS-R), a reliable toolthat can distinguish patients in the minimally con-scious state from those in a vegetative state.

2 The CRS-Rconsists of 29 hierarchically organised items dividedinto 6 subscales addressing auditory, visual, motor,oromotor, communication, and arousal translation procedure, designed to ensure the de-velopment of an italian version of the CRS-R that mir-rors the structure and content of the original, was thefollowing: three translations of the scale were concur-rently completed by authors from the groups involvedin the study; a selected version underwent back trans-lation to detect errors in translation and to ensure thatthere was no misinterpretation of administration andscoring guidelines; a consensus meeting was held toagree on a fully comprehensible and accurate Italiantranslation that was consistent with the original Englishtext; the authors of the original version were consultedfor additional assistance with translation when consen-sus could not be reached; a final back translation wasdone based on the agreed italian italian version of the scale is now available for usein clinical practice and in studies designed to investi-gate its psychometric properties; this will help in thecoordination of multicentre studies to assess its relia-bility.

3 KEY WORDS: coma, coma recovery scale , minimally consciousstate, vegetative progress has been made during the past tenyears in the rehabilitation of post-comatose patients,starting with the dissemination of uniform nomenclatureand specific diagnostic criteria for the neurobehaviouralassessment of patients with disorders of consciousness(DOC) (1). A major contribution was made by the AspenWorkgoup which first described the minimally consciousstate (MCS), a neurological condition characterised byinconsistent but definite behavioural evidence of con-sciousness usually signalling a transition from coma ora vegetative state (2). Another important developmentwas the publication of the Coma Recovery scale -Re-vised (CRS-R), a standardised neurobehavioural instru-ment designed for use in patients with DOC (3).

4 Among the several scales developed for the evaluationof such patients, the CRS-R is unique as it expressly in-corporates current diagnostic criteria for coma, vegeta-tive state, and the MCS, allowing the examiner to makea diagnosis based directly on bedside behavioural ob-servations (4).Standardised evaluation of the level of consciousness ina patient recovering from coma is essential to ensureaccurate longitudinal tracking of the patient's improve-ment and efficient planning of care, and for bioethics-and research-related reasons. An accurate diagnosis allows a more precise and reli-able prognosis of the course of the disease (5) and al-lows the relatives questions to receive competent andreliable answers. The importance of this aspect cannotbe underestimated since lack of uniformity, consistency,and precision reduces the professionals credibility, cre-ating conflicts between health workers and family mem-bers.

5 Moreover, diagnostic accuracy facilitates long-termtreatment planning (5-7) and provides information usefulfor deciding hospital-based courses of care, such as aperiod in the intensive rehabilitation unit or the patient sparticipation in a personalised rehabilitation programme(8). It is also a necessary step towards improving thequality of scientific research. Consistent use of terminol-ogy and of clear diagnostic criteria are indispensableprerequisites for the comparability and reproducibility ofany study (4,9,10). For these reasons, diagnostic as-sessment of level of consciousness cannot be perfunc-tory, based on hasty observations, or performed by peo-ple lacking the necessary expertise (11). The Coma Recovery scale -RevisedThe revisedversion of the CRS (3) was proposed to re-solve shortcomings presented by the original version ofthe scale (12-14), and to update it according to the rec-Functional Neurology 2007; 22(1): 47-6147 The italian version of the Coma Recovery scale -Revised (CRS-R)ommendations of the Aspen Workgroup (2).

6 A recentstudy of the American version demonstrated that theCRS-R is a reliable tool that can distinguish patients inthe MCS from those in a vegetative state (3). The CRS-R integrates neuropsychological assessmentwith clinical assessment and has been validated in pa-tients in a vegetative state and in the MCS (2,3,5,13,15).The amendments introduced in the CRS-R were basedon clinical experience and the need to include those be-havioural criteria that were deemed necessary to diag-nose the MCS (2). The CRS-R is a unique tool which includes the currentdiagnostic criteria for coma, vegetative state, and theMCS, and allows the patient to be assigned to the mostappropriate diagnostic category (3).The CRS-R consists of 29 hierarchically organiseditems divided into 6 subscales addressing auditory, visu-al, motor, oromotor, communication, and arousalprocesses.

7 Scoring is based on the presence or ab-sence of specific behavioural responses to sensorystimuli administered in a standardised manner. The low-est item on each subscale represents reflexive activity,whereas the highest items represent cognitively mediat-ed behaviours. The total score ranges between 0, theworst, and 23, the best. A score less than or equal to 2on the auditory, motor, and oromotor/verbal subscalesand less than or equal to 1 on the visual subscale, andof 0 on the communication subscale is consistent withthe diagnosis of vegetative state. A score of 3-4 on theauditory subscale, or of 2-5 on the visual subscale, or of3-5 on the motor subscale, or of 3 on the oromotor/ver-bal subscale, or of 1 on the communication subscale isconsistent with the diagnosis of MCS (3).

8 A score of 6 onthe motor subscale or of 2 on the communication sub- scale indicates emergence from the CRS-R is an appropriate measure for characteris-ing level of consciousness and for monitoring recoveryof neurobehavioural function (3). Changes compared tothe original CRS detected within the first four weeks ofadmission to a rehabilitation setting were able to predictthe outcome at 1 year (15). Moreover, the use of a stan-dardised scale is mandatory in a research setting and asa contribution to ethical legislation. A good level of diag-nostic reliability is important in order to give relatives anaccurate prognosis, to make the best arrangements forthe patient, to plan the most appropriate treatmentmodality and time of discharge, and to design dedicatedhealthcare settings.

9 The italian version of the Coma Recovery scale -Revised In an effort to develop an italian version of the CRS Rthat mirrors the structure and content of the original, weused the following methodology: a) three translations of the scale were concurrently com-pleted by authors from the groups involved in the study;b) a selected version underwent back translation to de-tect errors in translation and to ensure that there wasno misinterpretation of administration and scoringguidelines;c) a consensus meeting was held to agree on a fullycomprehensible and accurate italian translation thatwas consistent with the original English text;d) the authors of the original version were consulted foradditional assistance with translation when consen-sus could not be reached;e) a final back translation was done based on theagreed italian version.

10 The italian version of the scale is now available for usein clinical practice and in studies designed to investi-gate its psychometric properties; this will help in thecoordination of multicentre studies to assess its American Congress of Rehabilitation Medicine (ACRM).Recommendations for use of uniform nomenclature perti-nent to patients with severe alterations in Phys Med Rehabil 1995;76:205-20912. Giacino JT, Childs N, Jennet B et al. The minimally con-scious state: definition and diagnostic criteria. Neurology2002;58:349-35313. Giacino JT, Kalmar K, Whyte J. The JFK Coma RecoveryScale-Revised: measurement characteristics and diagnos-tic utility. Arch Phys Med Rehabil 2004; 85:2020-202914. Giacino JT. The minimally conscious state: defining theborders of consciousness.


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