Neurobehavioral Progress and Signs of Transition in Children With Prolonged Disorders of Consciousness: A Retrospective Longitudinal Study With the Coma Recovery Scale-Revised.

BACKGROUND: Research on disorders of consciousness in children is scarce and includes disparate and barely comparable participants and assessment instruments and therefore provides inconclusive information on the clinical progress and recovery in this population. This study retrospectively investigated the neurobehavioral progress and the signs of transition between states of consciousness in a group of children admitted to a rehabilitation program either with an unresponsive wakefulness syndrome (UWS) or in a minimally conscious state (MCS). METHODS: Systematic weekly assessments were conducted with the Coma Recovery Scale-Revised (CRS-R) until emergence from MCS, discharge, or death. RESULTS: Twenty-one children, nine admitted with a UWS and 12 admitted in an MCS, were included in the study. Four children with a UWS transitioned to an MCS with a CRS-R of 10 (9.2 to 12.2) by showing visual pursuit, visual fixation, or localization to noxious stimulation. Twelve children emerged from the MCS with a CRS-R of 20.5 (19 to 21.7). Children who emerged from the MCS had had a shorter time postinjury and higher CRS-R at admission, compared with those who did not emerge. CONCLUSIONS: Almost half of the children who were admitted with a UWS transitioned to an MCS, and almost all who were admitted in an MCS emerged from this state. Children who emerged had shorter times since injury and higher scores on the CRS-R at admission, compared with those who did not emerge.

Minimally conscious state plus versus minus: Likelihood of emergence and long-term functional independence.

OBJECTIVE: Severe brain injuries can result in disorders of consciousness, such as the Minimally Conscious State (MCS), where individuals display intermittent yet discernible signs of conscious awareness. The varied levels of responsiveness and awareness observed in this state have spurred the progressive delineation of two subgroups within MCS, termed "plus" (MCS+) and "minus" (MCS-). However, the clinical validity of these classifications remains uncertain. This study aimed to investigate and compare the likelihood of emergence from MCS, as well as the functional independence after emergence, in individuals categorized as in MCS+ and MCS-. METHODS: Demographic and behavioral data of 80 participants, admitted as either in MCS+ (n = 30) or MCS- (n = 50) to a long-term neurorehabilitation unit, were retrospectively analyzed. The neurobehavioral condition of each participant was evaluated weekly until discharge, demise, or emergence from MCS. The functional independence of those participants who emerged from MCS was assessed 6 months after emergence. RESULTS: While only about half of the individuals classified as in MCS- (n = 24) emerged from the MCS, all those admitted as in MCS+ did, and in a shorter postinjury period. Despite these differences, all individuals who emerged from the MCS demonstrated similar high disability and low functional independence 6 months after emergence, regardless of their state at admission. INTERPRETATION: Individuals classified as MCS+ exhibited a higher likelihood of emergence and a shorter time to emergence compared to those in MCS-. However, the level of functional independence 6 months after emergence was found to be unrelated to the initial state at admission.

Which information derived from the Coma Recovery Scale-Revised provides the most reliable prediction of clinical diagnosis and recovery of consciousness? A comparative study using machine learning techniques.

BACKGROUND: The Coma Recovery Scale-Revised (CRS-R) is the most recommended clinical tool to examine the neurobehavioral condition of individuals with disorders of consciousness (DOCs). Different studies have investigated the prognostic value of the information provided by the conventional administration of the scale, while other measures derived from the scale have been proposed to improve the prognosis of DOCs. However, the heterogeneity of the data used in the different studies prevents a reliable comparison of the identified predictors and measures. AIM: This study investigates which information derived from the CRS-R provides the most reliable prediction of both the clinical diagnosis and recovery of consciousness at the discharge of a long-term neurorehabilitation program. DESIGN: Retrospective observational multisite study. SETTING: The enrollment was performed in three neurorehabilitation facilities of the same hospital network. POPULATION: A total of 171 individuals with DOCs admitted to an inpatient neurorehabilitation program for a minimum of 3 months were enrolled. METHODS: Machine learning classifiers were trained to predict the clinical diagnosis and recovery of consciousness at discharge using clinical confounders and different metrics extracted from the CRS-R scale. RESULTS: Results showed that the neurobehavioral state at discharge was predicted with acceptable and comparable predictive value with all the indices and measures derived from the CRS-R, but for the clinical diagnosis and the Consciousness Domain Index, and the recovery of consciousness was predicted with higher accuracy and similarly by all the investigated measures, with the exception of initial clinical diagnosis. CONCLUSIONS: Interestingly, the total score in the CRS-R and, especially, the total score in its subscales provided the best overall results, in contrast to the clinical diagnosis, which could indicate that a comprehensive measure of the clinical diagnosis rather than the condition of the individuals could provide a more reliable prediction of the neurobehavioral progress of individuals with prolonged DOC. CLINICAL REHABILITATION IMPACT: The results of this work have important implications in clinical practice, offering a more accurate prognosis of patients and thus giving the possibility to personalize and optimize the rehabilitation plan of patients with DoC using low-cost and easily collectable information.

Reliability and validity of the Spanish adaptation of the Functional Independence Measure + Functional Assessment Measure.

BACKGROUND: The Functional Independence Measure + Functional Assessment Measure (FIM+FAM) Scale is one of the most widely used instruments to measure functional independence post-stroke, and features many cultural adaptations to various languages. AIM: The aim of this study was to determine the psychometric properties of a Spanish cross-cultural adaptation of the FIM+FAM for use in the stroke population. DESIGN: Observational study. SETTING: Outpatient long-term service of a neurorehabilitation unit. POPULATION: One hundred and twenty-two individuals with stroke. METHODS: The functional independence of the participants was assessed with the adapted version of the FIM+FAM. Additionally, the functional, motor and cognitive condition of the participants was assessed with a battery of standardized clinical instruments. Finally, a group of 31 participants out of the total were evaluated a second time with the FIM+FAM by a different evaluator than the one who performed the first evaluation. Internal consistency, inter-rater reliability and convergent validity with other clinical instruments of the adapted version of the FIM+FAM were determined. RESULTS: The internal consistency of the adapted version of the FIM+FAM was excellent, as evidenced by Cronbach's α values that exceeded 0.973. The inter-rater reliability was likewise excellent, with correlations above 0.990 in all domains and subscales. Additionally, the convergent validity of the scale adaptation with clinical instruments was variable, with values ranging from 0.264 to 0.983, but consistent with the construct assessed in the different instruments examined. CONCLUSIONS: The internal consistency, inter-rater reliability and convergent validity of the Spanish-adapted version of the FIM+FAM Scale showed excellent reliability and validity of the adaptation, which supports its use to assess functional independence after stroke. CLINICAL REHABILITATION IMPACT: Availability of a valid adaptation for the evaluation of functional independence after stroke in Spanish population.

Effectiveness of a combined transcranial direct current stimulation and virtual reality-based intervention on upper limb function in chronic individuals post-stroke with persistent severe hemiparesis: a randomized controlled trial.

BACKGROUND: Functional impairments derived from the non-use of severely affected upper limb after stroke have been proposed to be mitigated by action observation and imagination-based techniques, whose effectiveness is enhanced when combined with transcranial direct current stimulation (tDCS). Preliminary studies in mildly impaired individuals in the acute phase post-stroke show intensified effects when action is facilitated by tDCS and mediated by virtual reality (VR) but the effectiveness in cases of severe impairment and chronic stroke is unknown. This study investigated the effectiveness of a combined tDCS and VR-based intervention in the sensorimotor function of chronic individuals post-stroke with persistent severe hemiparesis compared to conventional physical therapy. METHODS: Twenty-nine participants were randomized into an experimental group, who received 30 minutes of the combined tDCS and VR-based therapy and 30 minutes of conventional physical therapy, or a control group, who exclusively received conventional physical therapy focusing on passive and active assistive range of motion exercises. The sensorimotor function of all participants was assessed before and after 25 one-hour sessions, administered three to five times a week, using the upper extremity subscale of the Fugl-Meyer Assessment, the time and ability subscales of the Wolf Motor Function Test, and the Nottingham Sensory Assessment. RESULTS: A clinically meaningful improvement of the upper limb motor function was consistently revealed in all motor measures after the experimental intervention, but not after conventional physical therapy. Similar limited effects were detected in the sensory function in both groups. CONCLUSION: The combined tDCS and VR-based paradigm provided not only greater but also clinically meaningful improvement in the motor function (and similar sensory effects) in comparison to conventional physical therapy.

When, How, and to What Extent Are Individuals with Unresponsive Wakefulness Syndrome Able to Progress? Neurobehavioral Progress.

Accurate estimation of the neurobehavioral progress of patients with unresponsive wakefulness syndrome (UWS) is essential to anticipate their most likely clinical course and guide clinical decision making. Although different studies have described this progress and possible predictors of neurobehavioral improvement in these patients, they have methodological limitations that could restrict the validity and generalization of the results. This study investigates the neurobehavioral progress of 100 patients with UWS consecutively admitted to a neurorehabilitation center using systematic weekly assessments based on standardized measures, and the prognostic factors of changes in their neurobehavioral condition. Our results showed that, during the analyzed period, 34% of the patients were able to progress from UWS to minimally conscious state (MCS), 12% of the total sample (near one third from those who progressed to MCS) were able to emerge from MCS, and 10% of the patients died. Transition to MCS was mostly denoted by visual signs, which appeared either alone or in combination with motor signs, and was predicted by etiology and the score on the Coma Recovery Scale-Revised at admission with an accuracy of 75%. Emergence from MCS was denoted in the same proportion by functional communication and object use. Predictive models of emergence from MCS and mortality were not valid and the identified predictors could not be accounted for.

When, How, and to What Extent Are Individuals with Unresponsive Wakefulness Syndrome Able to Progress? Functional Independence.

Accurate estimation of the functional independence of patients with unresponsive wakefulness syndrome (UWS) is essential to adjust family and clinical expectations and plan long-term necessary resources. Although different studies have described the clinical course of these patients, they have methodological limitations that could restrict generalization of the results. This study investigates the neurobehavioral progress of 100 patients with UWS consecutively admitted to a neurorehabilitation center using systematic weekly assessments based on standardized measures, and the functional independence staging of those patients who emerged from a minimally conscious state (MCS) during the first year post-emergence. Our results showed that one year after emergence, most patients were severely dependent, although some of them showed extreme or moderate severity. Clinically meaningful functional improvement was less likely to occur in cognitively-demanding activities, such as activities of daily living and executive function. Consequently, the use of specific and staging functional independence measures, with domain-specific evaluations, are recommended to detect the functional changes that might be expected in these patients. The information provided by these instruments, together with that obtained from repeated assessments of the preserved consciousness with standardized instruments, could help clinicians to adjust expectations and plan necessary resources for this population.

Gait analysis with the Kinect v2: normative study with healthy individuals and comprehensive study of its sensitivity, validity, and reliability in individuals with stroke.

BACKGROUND: Gait is usually assessed by clinical tests, which may have poor accuracy and be biased, or instrumented systems, which potentially solve these limitations at the cost of being time-consuming and expensive. The different versions of the Microsoft Kinect have enabled human motion tracking without using wearable sensors at a low-cost and with acceptable reliability. This study aims: First, to determine the sensitivity of an open-access Kinect v2-based gait analysis system to motor disability and aging; Second, to determine its concurrent validity with standardized clinical tests in individuals with stroke; Third, to quantify its inter and intra-rater reliability, standard error of measurement, minimal detectable change; And, finally, to investigate its ability to identify fall risk after stroke. METHODS: The most widely used spatiotemporal and kinematic gait parameters of 82 individuals post-stroke and 355 healthy subjects were estimated with the Kinect v2-based system. In addition, participants with stroke were assessed with the Dynamic Gait Index, the 1-min Walking Test, and the 10-m Walking Test. RESULTS: The system successfully characterized the performance of both groups. Significant concurrent validity with correlations of variable strength was detected between all clinical tests and gait measures. Excellent inter and intra-rater reliability was evidenced for almost all measures. Minimal detectable change was variable, with poorer results for kinematic parameters. Almost all gait parameters proved to identify fall risk. CONCLUSIONS: Results suggest that although its limited sensitivity to kinematic parameters, the Kinect v2-based gait analysis could be used as a low-cost alternative to laboratory-grade systems to complement gait assessment in clinical settings.

Combined Transcranial Direct Current Stimulation and Virtual Reality-Based Paradigm for Upper Limb Rehabilitation in Individuals with Restricted Movements. A Feasibility Study with a Chronic Stroke Survivor with Severe Hemiparesis.

Impairments of the upper limb function are a major cause of disability and rehabilitation. Most of the available therapeutic options are based on active exercises and on motor and attentional inclusion of the affected arm in task oriented movements. However, active movements may not be possible after severe impairment of the upper limbs. Different techniques, such as mirror therapy, motor imagery, and non-invasive brain stimulation have been shown to elicit cortical activity in absence of movements, which could be used to preserve the available neural circuits and promote motor learning. We present a virtual reality-based paradigm for upper limb rehabilitation that allows for interaction of individuals with restricted movements from active responses triggered when they attempt to perform a movement. The experimental system also provides multisensory stimulation in the visual, auditory, and tactile channels, and transcranial direct current stimulation coherent to the observed movements. A feasibility study with a chronic stroke survivor with severe hemiparesis who seemed to reach a rehabilitation plateau after two years of its inclusion in a physical therapy program showed clinically meaningful improvement of the upper limb function after the experimental intervention and maintenance of gains in both the body function and activity. The experimental intervention also was reported to be usable and motivating. Although very preliminary, these results could highlight the potential of this intervention to promote functional recovery in severe impairments of the upper limb.

Reliability and comparison of Kinect-based methods for estimating spatiotemporal gait parameters of healthy and post-stroke individuals.

Different studies have analyzed the potential of the off-the-shelf Microsoft Kinect, in its different versions, to estimate spatiotemporal gait parameters as a portable markerless low-cost alternative to laboratory grade systems. However, variability in populations, measures, and methodologies prevents accurate comparison of the results. The objective of this study was to determine and compare the reliability of the existing Kinect-based methods to estimate spatiotemporal gait parameters in healthy and post-stroke adults. Forty-five healthy individuals and thirty-eight stroke survivors participated in this study. Participants walked five meters at a comfortable speed and their spatiotemporal gait parameters were estimated from the data retrieved by a Kinect v2, using the most common methods in the literature, and by visual inspection of the videotaped performance. Errors between both estimations were computed. For both healthy and post-stroke participants, highest accuracy was obtained when using the speed of the ankles to estimate gait speed (3.6-5.5 cm/s), stride length (2.5-5.5 cm), and stride time (about 45 ms), and when using the distance between the sacrum and the ankles and toes to estimate double support time (about 65 ms) and swing time (60-90 ms). Although the accuracy of these methods is limited, these measures could occasionally complement traditional tools.

Effect of a mixed reality-based intervention on arm, hand, and finger function on chronic stroke.

BACKGROUND: Virtual and mixed reality systems have been suggested to promote motor recovery after stroke. Basing on the existing evidence on motor learning, we have developed a portable and low-cost mixed reality tabletop system that transforms a conventional table in a virtual environment for upper limb rehabilitation. The system allows intensive and customized training of a wide range of arm, hand, and finger movements and enables interaction with tangible objects, while providing audiovisual feedback of the participants' performance in gamified tasks. This study evaluates the clinical effectiveness and the acceptance of an experimental intervention with the system in chronic stroke survivors. METHODS: Thirty individuals with stroke were included in a reversal (A-B-A) study. Phase A consisted of 30 sessions of conventional physical therapy. Phase B consisted of 30 training sessions with the experimental system. Both interventions involved flexion and extension of the elbow, wrist, and fingers, and grasping of different objects. Sessions were 45-min long and were administered three to five days a week. The body structures (Modified Ashworth Scale), functions (Motricity Index, Fugl-Meyer Assessment Scale), activities (Manual Function Test, Wolf Motor Function Test, Box and Blocks Test, Nine Hole Peg Test), and participation (Motor Activity Log) were assessed before and after each phase. Acceptance of the system was also assessed after phase B (System Usability Scale, Intrinsic Motivation Inventory). RESULTS: Significant improvement was detected after the intervention with the system in the activity, both in arm function measured by the Wolf Motor Function Test (p < 0.01) and finger dexterity measured by the Box and Blocks Test (p < 0.01) and the Nine Hole Peg Test (p < 0.01); and participation (p < 0.01), which was maintained to the end of the study. The experimental system was reported as highly usable, enjoyable, and motivating. CONCLUSIONS: Our results support the clinical effectiveness of mixed reality interventions that satisfy the motor learning principles for upper limb rehabilitation in chronic stroke survivors. This characteristic, together with the low cost of the system, its portability, and its acceptance could promote the integration of these systems in the clinical practice as an alternative to more expensive systems, such as robotic instruments.

Mirror therapy in chronic stroke survivors with severely impaired upper limb function: a randomized controlled trial.

BACKGROUND: Mirror therapy (MT) has been proposed to improve the motor function of chronic individuals with stroke with mild to moderate impairment. With regards to severe upper limb paresis, MT has shown to provide limited motor improvement in the acute or sub-acute phase. However, no previous research has described the effects of MT in chronic individuals with stroke with severely impaired upper limb function. AIM: The aim of this study was to determine the effectiveness of MT on chronic stroke survivors with severe upper-limb impairment in comparison with passive mobilization. DESIGN: A randomized controlled trial. SETTING: Rehabilitative outpatient unit. POPULATION: A total of 31 chronic subjects poststroke with severely impaired upper limb function were randomly assigned to either an experimental group (N.=15), or a control group (N.=16). METHODS: Twenty-four intervention sessions were performed for both groups. Each session included 45-minute period of MT (experimental group) or passive mobilization (control group), administered three days a week. Participants were assessed before and after the intervention with the Wolf Motor Function Test, the Fugl-Meyer Assessment, and the Nottingham Sensory Assessment. RESULTS: Improvement in motor function was observed in both groups on the time (P=0.002) and ability (P=0.001) subscales of the Wolf Motor Function Test. No differences were detected in kinesthesis or stereognosis. However, the experimental group showed a significant improvement in tactile sensation that was mainly observed as an increased sensitivity to light touches. CONCLUSIONS: In comparison with passive mobilization, MT in chronic stroke survivors with severely impaired upper-limb function may provide a limited but positive effect on light touch sensitivity while providing similar motor improvement. CLINICAL REHABILITATION IMPACT: MT is a therapeutic approach that can be used in the rehabilitation of severely impaired upper limb in chronic stroke survivors, specifically to address light touch sensitivity deficits.

Improvement in balance using a virtual reality-based stepping exercise: a randomized controlled trial involving individuals with chronic stroke.

OBJECTIVE: To study the clinical effectiveness and the usability of a virtual reality-based intervention compared with conventional physical therapy in the balance recovery of individuals with chronic stroke. DESIGN: Randomized controlled trial. SETTING: Outpatient neurorehabilitation unit. PARTICIPANTS: A total of 20 individuals with chronic stroke. INTERVENTIONS: The intervention consisted of 20 one-hour sessions, five sessions per week. The experimental group combined 30 minutes with the virtual reality-based intervention with 30 minutes of conventional training. The control group underwent one hour conventional therapy. MAIN MEASURES: Balance performance was assessed at the beginning and at the end of the trial using the Berg Balance Scale, the balance and gait subscales of the Tinetti Performance-Oriented Mobility Assessment, the Brunel Balance Assessment, and the 10-m Walking Test. Subjective data of the virtual reality-based intervention were collected from the experimental group, with a feedback questionnaire at the end of the trial. RESULTS: The results revealed a significant group-by-time interaction in the scores of the Berg Balance Scale (p < 0.05) and in the 10-m Walking Test (p < 0.05). Post-hoc analyses showed greater improvement in the experimental group: 3.8 ±2.6 vs. 1.8 ±1.4 in the Berg Balance Scale, -1.9 ±1.6 seconds vs. 0.0 ±2.3 seconds in the 10-m Walking Test, and also in the number of participants who increased level in the Brunel Balance Assessment (χ(2) = 2.5, p < 0.01). CONCLUSIONS: Virtual reality interventions can be an effective resource to enhance the improvement of balance in individuals with chronic stroke.

Effectiveness, usability, and cost-benefit of a virtual reality-based telerehabilitation program for balance recovery after stroke: a randomized controlled trial.

OBJECTIVES: First, to evaluate the clinical effectiveness of a virtual reality (VR)-based telerehabilitation program in the balance recovery of individuals with hemiparesis after stroke in comparison with an in-clinic program; second, to compare the subjective experiences; and third, to contrast the costs of both programs. DESIGN: Single-blind, randomized, controlled trial. SETTING: Neurorehabilitation unit. PARTICIPANTS: Chronic outpatients with stroke (N=30) with residual hemiparesis. INTERVENTIONS: Twenty 45-minute training sessions with the telerehabilitation system, conducted 3 times a week, in the clinic or in the home. MAIN OUTCOME MEASURES: First, Berg Balance Scale for balance assessment. The Performance-Oriented Mobility Assessment balance and gait subscales, and the Brunel Balance Assessment were secondary outcome measures. Clinical assessments were conducted at baseline, 8 weeks (posttreatment), and 12 weeks (follow-up). Second, the System Usability Scale and the Intrinsic Motivation Inventory for subjective experiences. Third, cost (in dollars). RESULTS: Significant improvement in both groups (in-clinic group [control] and a home-based telerehabilitation group) from the initial to the final assessment in the Berg Balance Scale (ηp(2)=.68; P=.001), in the balance (ηp(2)=.24; P=.006) and gait (ηp(2)=.57, P=.001) subscales of the Tinetti Performance-Oriented Mobility Assessment, and in the Brunel Balance Assessment (control: χ(2)=15.0; P=.002; experimental: χ(2)=21.9; P=.001). No significant differences were found between the groups in any balance scale or in the feedback questionnaires. With regard to subjective experiences, both groups considered the VR system similarly usable and motivating. The in-clinic intervention resulted in more expenses than did the telerehabilitation intervention ($654.72 per person). CONCLUSIONS: First, VR-based telerehabilitation interventions can promote the reacquisition of locomotor skills associated with balance in the same way as do in-clinic interventions, both complemented with a conventional therapy program; second, the usability of and motivation to use the 2 interventions can be similar; and third, telerehabilitation interventions can involve savings that vary depending on each scenario.

Progression of posturographic findings after acquired brain injury.

OBJECTIVE: To study the characteristics of balance performance in a sample of patients with increasing postural instability after acquired brain injury (ABI) and to establish the clinical utility of a new computerized posturographic system (NedSVE/IBV). METHODS: This study included 108 patients with ABI divided into five groups from minimal to severe postural impairment. All patients were assessed with the NedSVE/IBV system and with traditional balance measures. Posturographic analyses included the modified clinical test of sensory interaction on balance, the limits of stability and the weight-shifting test. Sensitivity to detect changes and reproducibility were evaluated in 63 patients who were followed-up for 6 months and in 20 patients who were evaluated on two separate occasions during the same week, respectively. RESULTS: The patients showed reduced stability limits, abnormal postural responses and an increased reliance on visual input with differences in intensity directly related to their degree of balance impairment. Posturographic study showed excellent convergent validity, reproducibility and sensitivity to detect changes. CONCLUSION: The data suggests that, regardless of the intensity of postural instability, there is a common mechanism of sensory processing to maintain balance after ABI. The NedSVE-IBV system is a valid tool to quantify balance after ABI.

Balance recovery through virtual stepping exercises using Kinect skeleton tracking: a follow-up study with chronic stroke patients.

Stroke patients often suffer from hemiparesis, which affects their balance condition and consequently their self-dependency and quality of life. Balance rehabilitation can be a long and tedious process. Virtual rehabilitation systems have been reported to provide therapeutic benefits to the balance recovery of stroke patients while increasing their motivation. This paper presents a follow-up study involving chronic stroke patients to evaluate the clinical effectiveness of a virtual stepping exercise using skeleton tracking through a low-cost Kinect depth sensor.

Behavioral recovery in disorders of consciousness: a prospective study with the Spanish version of the Coma Recovery Scale-Revised.

OBJECTIVE: To describe the clinical characteristics and short-term pattern of evolution of a sample of patients within 1 year after acquiring a brain injury that led to a vegetative state (VS) or a minimally conscious state (MCS). DESIGN: Cohort study. SETTING: Inpatient brain injury rehabilitation program. PARTICIPANTS: Patients with acquired brain injury (N=32; 47% traumatic, 37.5% hemorrhagic, 15.5% anoxic) who were in a VS or an MCS according to Coma Recovery Scale-Revised (CRS-R) scores. INTERVENTION: Integrative multisensory program comprising daily physical rehabilitation procedures and multimodal sensory stimulation. MAIN OUTCOME MEASURE: All patients were assessed with a Spanish version of the CRS-R at admission and then monthly for at least 6 months or until emergence from MCS. RESULTS: At the time of admission, 12 patients were diagnosed as being in a VS and 20 as being in an MCS. Eight patients were able to emerge from their MCS during follow-up. Seven of these 8 patients were diagnosed as being in an MCS at inclusion, and only 1 was diagnosed as being in a VS. Emergence from an MCS was mostly associated with improvement in both the communication and motor function scales (n=4). Lesser chronicity (P=.01) and the presence of more than visual behavioral responses at admission (P=.05) were both significant predictors of emergence from an MCS. CONCLUSIONS: The CRS-R seems appropriate for establishing an immediate prognosis in this population. A quick referral of these patients for specialized assessment and rehabilitation facilities is recommended.