Assessment of Consciousness with the CRS-R, Does Position Matter?

Research Objectives: To assess the impact of patient positioning on assessment of consciousness in patients with a disorder of consciousness (DoC) using the Coma Recovery Scale-Revised.

Design: Retrospective chart view.

Setting: Acute inpatient rehabilitation.

Participants: 174 patients (mean age = 36.4 years, SD = 16.4; 61% male) with DoC admitted between 2020 and 2023 received serial CRS-R assessments. Mean length of admission was 48 days and mean number of CRS-R administrations per patient was 6.

Interventions: Intensive physical, occupational, speech therapies with transdisciplinary management in a specialized disorders of consciousness program.

Main Outcome Measures: Primary Outcome: Total CRS-R score; Secondary Outcome: arousal scale score, number of arousal protocols administered.

Results: A one-way ANOVA revealed that there was a statistically significant difference in CRS-R total score across positions (F(3, 1066) = 8.012, p < .001). Tukey’s HSD Test revealed that performance on CRS-R in bed was significantly worse than at edge of mat (p < .001), standing (p = .019), or in a wheelchair (p = .002). There was a statistically significant difference in arousal scale score by position (F(3, 1082) = 5.722, p = .001). Tukey’s HSD Test revealed that patients scored significantly lower on the arousal scale when in bed than at edge of mat (p < .001) or in a wheelchair (p = .006), and they required significantly more arousal protocols when in bed than at edge of mat (p = .043).

Conclusions: When patients were in bed, they performed significantly worse overall on the CRS-R compared to when in all other positions. Their arousal levels were significantly worse when in bed than at edge of mat or in a wheelchair. Our findings denote the importance of avoiding positions that promote hypoarousal in patients with a DoC. CRS-R performed in a more alerting, upright position will likely increase the chance of accurate identification of the level of consciousness. Inaccurate diagnosis may lead to barriers accessing appropriate levels of rehabilitation care.

Author(s) Disclosures: No disclosures to report.