Association of Patient Characteristics With Recovery in Adults With Disorders of Consciousness.

Among 696 adults with disorders of consciousness after severe brain injury in specialized rehabilitation programs, two-thirds improved beyond measurement error on the Coma Recovery Scale-Revised, while 23 declined and 228 showed no reliable change. Patients who began rehabilitation sooner after injury were more likely to show true improvement. Early change during the first two weeks did not predict change in the following two weeks, indicating that progress is not linear and that precise measurement is needed to guide treatment decisions.

Study at a glance

Abstract

To describe the characteristics of patients enrolled in disorders of consciousness (DoC) rehabilitation programs and to examine factors associated with improvement beyond measurement error on neurobehavioral function. Outcomes for adults with DoC after severe brain injury are highly variable and difficult to predict. Applying a minimal detectable change (MDC) threshold to change measures can identify help to distinguish true improvement or decline from random fluctuation. We also evaluated whether change in neurobehavioral function during the first 2 weeks of rehabilitation was associated with change between 2 and 4 weeks. Retrospective cohort study. Data were generated as part of standard clinical care. Postacute inpatient facilities with specialized DoC programs at 2 large, urban health care systems. Adults with DoC after severe brain injury (N=696). Not applicable. Improvement beyond measurement error, calculated as the MDC with a 90% confidence interval (9 units) on the Coma Recovery Scale-Revised (CRS-R), using an equal-interval 0-100 unit transformed total measure. The MDC threshold was applied to change in CRS-R total measure from first to last CRS-R administration (up to 60 elapsed). Two-thirds of the sample (n=445) improved beyond the MDC on the CRS-R; 23 participants declined beyond measurement error, and 228 participants changed less than the MDC. Patients with less time elapsed between injury and first CRS-R assessment were more likely to improve beyond the MDC. Change during the first 2 weeks of rehabilitation was not associated with change between 2 and 4 weeks. Our results underscore the importance of measuring change with greater precision for adults with DoC, as within-state change (or lack thereof) could inform rehabilitation treatment decisions about whether interventions are working as intended.