Differences in Coma Recovery Scale-Revised performance in an upright position versus lying position

The study investigated the impact of patient positioning on behavioral assessment of consciousness in individuals with a disorder of consciousness (DoC) using the Coma Recovery Scale-Revised (CRS-R). In this retrospective study, 1,470 CRS-R assessments were performed on 232 patients in four different positions: lying in bed (Bed), sitting at edge of mat (Mat), sitting in a wheelchair (Wheelchair), and standing (Standing), in an acute inpatient rehabilitation setting. A conditional random coefficients multi-level model was used to examine changes in the transformed CRS-R total unit (which converted the raw CRS-R total score to an equal-interval scale) across positions, accounting for repeated measurements within subjects and variability introduced by different raters. Transformed CRS-R total unit was significantly associated with assessment position. Compared to the Bed position (controlling age, gender, etiology, number of arousal protocol used, and days post-injury), patients assessed in the Wheelchair, Mat, and Standing positions had estimated 2.7-, 3.2-, and 3.5-unit increases in the transformed CRS-R total unit (p = 0.02, 0.01, and 0.11), respectively. Number of arousal protocols used was not significantly associated with assessment position. Increased use of these protocols did not enhance CRS-R performance. Improved physical and cognitive functionality in an upright position, rather than arousal alone, may contribute to the improvements on the CRS-R. Our results revealed that patients scored higher on the CRS-R in an upright position compared to a lying position. This suggests that the CRS-R is better performed in an upright position instead of a lying position in patients with DoC. We recommend assessing the level of consciousness in patients with DoC in an upright position and out of bed whenever feasible.