Barra Alice, Bodien Yelena G, Tan Can Ozan, Martens Geraldine, Malone Christopher, Giacino Joseph T
IRENEA - Instituto de Rehabilitación Neurológica, Fundación Hospitales Vithas, València, Spain; Coma Science Group, GIGA Consciousness - GIGA Research, University of Liège, Liège, Belgium.
Spaulding Rehabilitation Hospital, Charlestown, MA; Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA; Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
Arch Phys Med Rehabil. 2025 Mar 24. doi: 10.1016/j.apmr.2025.03.038.
To assess the frequency of behavioral fluctuations in patients with prolonged disorders of consciousness (DoC), characterize the stability of consciousness ratings, and characterize the stability of behavioral signs of consciousness.
Prospective observational analysis.
Specialized DoC program in an inpatient rehabilitation facility and a long-term acute care hospital.
Patients in a vegetative state/unresponsive wakefulness state, minimally conscious state, and emerging from a minimally conscious state followed weekly by the Coma Recovery Scale-Revised (CRS-R) between 28 and 90days postinjury (N=241).
Change in CRS-R subscale scores and consciousness ratings.
Behavioral fluctuation was observed in >80% of patients and was most common in the CRS-R motor subscale and least common in the communication subscale (83% and 54% of patients experienced ≥1 fluctuation over the 3wk study period, respectively, with a 1-point change observed most frequently). Among patients who were conscious at baseline assessment, 25% were subsequently rated as unconscious at least once. Localization to pain and object manipulation were the most stable signs of consciousness, recurring at least 3 times after the first occurrence in ≥97% of the sample. Reproducible command-following and intelligible verbalization were the least stable, recurring at least 3 times after the first occurrence in ≤27% of the sample.
Patients with prolonged DoC who undergo serial assessment demonstrate a high rate of fluctuation in behavioral signs of consciousness. These findings highlight that repeated assessments are essential in this population, both to capture the highest level of consciousness and to help distinguish spontaneous fluctuation from response to treatment in interventional studies.
评估长期意识障碍（DoC）患者行为波动的频率，描述意识评分的稳定性，并描述意识行为体征的稳定性。
前瞻性观察分析。
一家住院康复机构和一家长期急性护理医院的专门DoC项目。
处于植物状态/无反应觉醒状态、最低意识状态以及从最低意识状态恢复的患者，在受伤后28至90天内每周接受一次修订版昏迷恢复量表（CRS-R）评估（N = 241）。
CRS-R子量表评分和意识评分的变化。
超过80%的患者观察到行为波动，在CRS-R运动子量表中最为常见，在交流子量表中最不常见（在3周的研究期间，分别有83%和54%的患者经历了≥1次波动，最常观察到1分的变化）。在基线评估时有意识的患者中，25%随后至少有一次被评为无意识。对疼痛的定位和物体操作是最稳定的意识体征，在样本中≥97%的患者首次出现后至少重复出现3次。可重复的指令遵循和可理解的言语表达最不稳定，在样本中≤27%的患者首次出现后至少重复出现3次。
接受系列评估的长期DoC患者意识行为体征波动发生率很高。这些发现突出表明，对这一人群进行重复评估至关重要，这既能捕捉到最高意识水平，又有助于在干预研究中区分自发波动与对治疗的反应。
