Assessment Scales for Disorders of Consciousness: Evidence-Based Recommendations for Clinical Practice and Research
Assessment Scales for Disorders of Consciousness: Evidence-Based Recommendations for Clinical Practice and Research
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DOI：
10.1016/j.apmr.2010.07.218
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发表时间：
2010-12-01
影响因子：
4.3
通讯作者：
Zasler, Nathan
中科院分区：
文献类型：
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作者：
Seel, Ronald T.;Sherer, Mark;Zasler, Nathan
美国康复医学大会报告，脑损伤-跨学科特别兴趣小组，意识障碍工作组：Seel RT，工作组主席，Sherer M, Whyte J, Katz DI, Giacino if, Rosenbaum AM, Hammond FM, Kalmar K, Pape TL, Zafonte R, Biester RC, Kaelin D, Kean J, Zasler N.意识障碍评估标准：临床实践和研究的基于证据的建议。中华医学杂志，2010;31(1):391 - 391。目的：对意识障碍行为评估量表（DOC）进行系统评价；根据内容效度、可靠性、诊断效度和预测功能结局的能力，为临床使用提供循证建议；为DOC量表的开发和验证提供研究建议。数据来源：截至2009年3月31日发表的文章，使用MEDLINE、CINAHL、心理学和行为科学合集、Cochrane系统评价数据库、效果评价摘要数据库、Cochrane对照试验中央注册库、生物医学参考文献合集和PsycINFO。定义DOC的13个主要术语与定义测量方面的30个次要术语配对。量表名称、缩略语和作者也被用作搜索条件。工作组成员通过运用个人知识和审查评审文章中的参考文献，确定了其他文章。研究选择：主要标准包括：(1)提供可靠性、诊断效度和/或预后效度数据；(2)检查年龄大于或等于18岁的DOC患者的队列、病例对照或病例系列样本；(3)在急性护理或康复环境中进行评估。如果没有进行同行评议，没有报告原始数据，或者没有英文文章，文章将被排除。最初的搜索产生了580篇文章。在对研究摘要进行配对评比后，指南的制定基于代表13个DOC量表的37篇文章。数据提取：通过使用美国神经病学学会的4层证据方案和使用工作组开发的3层证据方案，Rater对研究进行分类，解决诊断和预后的有效性问题。对评级进行了独立的质量审查，并进行了修正。数据综合：昏迷恢复量表-修订（CRS-R）、感觉刺激评估量表（SSAM）、威塞克斯头部损伤矩阵（WHIM）、西方神经感觉刺激谱（WNSSP）、感觉形态评估技术（SMART）、意识障碍量表（DOCS）和昏迷/近昏迷量表（CNC）有可接受的标准化管理和评分程序。CRS-R具有出色的内容效度，并且是唯一满足所有Aspen工作组标准的量表。SMART、SSAM、WHIM和WNSSP显示出良好的内容有效性，其中包含的项目可以区分处于植物人状态、处于最低意识状态（MCS）或从MCS中出现的人。无反应性完整大纲评分（FOUR）、WNSSP、CRS-R、综合意识水平量表（CLOCS）和因斯布鲁克昏迷量表（INNS）显示了大量的内部一致性证据。FOUR和CRS-R显示了大量证据表明具有良好的互信度。脑损伤幸存者样本中诊断有效性和预后有效性的证据存在非常高的潜在偏倚，因为方法学上的问题，如缺乏评分掩蔽。结论：CRS-R可用于轻度保留的DOC评估，SMART、WNSSP、SSAM、WHIM和DOCS可用于中度保留的DOC评估。CNC可用于评估DOC的主要保留。目前不推荐使用FOUR、INNS、Glasgow-Liege昏迷量表、瑞典反应水平量表-1985、Loewenstein沟通量表和CLOCS对DOC进行床边行为评估，因为缺乏内容效度、缺乏标准化和/或未经证实的可靠性。
Report of the American Congress of Rehabilitation Medicine, Brain Injury-Interdisciplinary Special Interest Group, Disorders of Consciousness Task Force: Seel RT, Task Force Chair, Sherer M, Whyte J, Katz DI, Giacino if, Rosenbaum AM, Hammond FM, Kalmar K, Pape TL, Zafonte R, Biester RC, Kaelin D, Kean J, Zasler N. Assessment scales for disorders of consciousness: evidence-based recommendations for clinical practice and research. Arch Phys Med Rehabil 2010;91:1795-1813.Objectives: To conduct a systematic review of behavioral assessment scales for disorders of consciousness (DOC); provide evidence-based recommendations for clinical use based on their content validity, reliability, diagnostic validity, and ability to predict functional outcomes; and provide research recommendations on DOC scale development and validation.Data Sources: Articles published through March 31, 2009, using MEDLINE, CINAHL, Psychology and Behavioral Sciences Collection, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, Biomedical Reference Collection, and PsycINFO. Thirteen primary terms that defined DOC were paired with 30 secondary terms that defined aspects of measurement. Scale names, abbreviations, and authors were also used as search terms. Task force members identified additional articles by using personal knowledge and examination of references in reviewed articles.Study Selection: Primary criteria included the following: (I) provided reliability, diagnostic validity, and/or prognostic validity data; (2) examined a cohort, case control, or case series sample of persons with DOC who were age older than or equal to 18 years; and (3) assessed in an acute care or rehabilitation setting. Articles were excluded if peer review was not conducted, original data were not reported, or an English language article was not available. The initial search yielded 580 articles. After paired rater review of study abstracts, guideline development was based on 37 articles representing 13 DOC scales.Data Extraction: Rater pairs classified studies addressing diagnostic and prognostic validity by using the American Academy of Neurology 4-tier level of evidence scheme, and reliability by using a task force developed 3-tier evidence scheme. An independent quality review of ratings was conducted, and corrections were made.Data Synthesis: The Coma Recovery Scale-Revised (CRS-R), Sensory Stimulation Assessment Measure (SSAM), Wessex Head Injury Matrix (WHIM), Western Neuro Sensory Stimulation Profile (WNSSP), Sensory Modality Assessment Technique (SMART), Disorders of Consciousness Scale (DOCS), and Coma/Near-Coma Scale (CNC) have acceptable standardized administration and scoring procedures. The CRS-R has excellent content validity and is the only scale to address all Aspen Work-group criteria. The SMART, SSAM, WHIM, and WNSSP demonstrate good content validity, containing items that could distinguish persons who are in a vegetative state, are in a minimally conscious state (MCS), or have emerged from MCS. The Full Outline of UnResponsiveness Score (FOUR), WNSSP, CRS-R, Comprehensive Levels of Consciousness Scale (CLOCS), and Innsbruck Coma Scale (INNS) showed substantial evidence of internal consistency. The FOUR and the CRS-R showed substantial evidence of good interrater reliability. Evidence of diagnostic validity and prognostic validity in brain injury survivor samples had very high levels of potential bias because of methodologic issues such as lack of rater masking.Conclusions: The CRS-R may be used to assess DOC with minor reservations, and the SMART, WNSSP, SSAM, WHIM, and DOCS may be used to assess DOC with moderate reservations. The CNC may be used to assess DOC with major reservations. The FOUR, INNS, Glasgow-Liege Coma Scale, Swedish Reaction Level Scale-1985, Loewenstein Communication Scale, and CLOCS are not recommended at this time for bedside behavioral assessment of DOC because of a lack of content validity, lack of standardization, and/or unproven reliability.