Consciousness Scales employed in the chronic Setting

Coma Recovery Scale-Revised (CRS-R)

View English manual & scoring sheet

View French manual & scoring sheet

View Flemish manual & scoring sheet

View German manual & scoring sheet

View Chinese scoring sheet

View Italian manual & scoring sheet

The CRS-R (Giacino et al. 2004) was specifically developed to differentiate vegetative (VS) from minimally conscious states (MCS) and to identify patients that have emerged from MCS. It explicitly incorporates the current diagnostic criteria for VS and MCS (Giacino et al. 2002) into its administration and scoring scheme, and is unique in allowing to derive a diagnosis directly from the examination findings. The basic structure of the CRS-R is similar to the GCS but its subscales are much more detailed targeting more subtle signs of recovery of consciousness. It includes auditory, visual, motor, oromotor/verbal, communication, and arousal subscales and ranges from 0 (worst) to 23 (best). This increased attention to subtle but potentially important clinical signs lengthens the administration time of the CRS-R and makes it more challenging to use in the intensive care setting. The Coma Science Group has translated the CRS-R in French and Dutch.

Giacino, J. T., S. Ashwal, N. Childs, R. Cranford, B. Jennett, D. I. Katz, J. P. Kelly, J. H. Rosenberg, J. Whyte, R. D. Zafonte and N. D. Zasler (2002). "The minimally conscious state: Definition and diagnostic criteria." Neurology 58(3): 349-353.
Giacino, J. T., K. Kalmar and J. Whyte (2004). "The JFK Coma Recovery Scale-Revised: measurement characteristics and diagnostic utility." Arch Phys Med Rehabil 85(12): 2020-9.


Wessex Head Injury Matrix (WHIM)

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View Chinese version

The Wessex Head Injury Matrix (WHIM), developed by Shiel et al. (2000) and based on previous work by Horn et al. (1992, 1993) and Wilson et al. (1994), was created by observing the behaviors that occurred spontaneously or in response to stimulation in a large cohort of initially comatose patients followed longitudinally over time. Following this initial phase of empirical observation, 145 behaviors were identified. These 145 behaviors were then categorized into 6 subscales (communication, attention, social behavior, concentration, visual awareness, and cognition) which were then assembled to form a single main scale of 62 items. Most importantly, these 62 items are ordered in a hierarchical way, the hierarchy of behaviors assessed reflecting a statistically derived order of recovery from coma: item 1 should appear before item 2, item 2 before item 3, etc… To obtain this hierarchy, the behaviors were ranked a posteriori as a function of order of appearance observed during recovery, using a paired preference technique, similar to the paired comparisons technique often used for the construction of ordinal scales (Watson and Horn, 1992; Watson et al., 1997).
The WHIM score represents the rank order of the most advanced item observed (rather than adding the different items observed). The WHIM was designed to monitor all stages of recovery from coma to emerging post-traumatic amnesia, to monitor subtle changes in patients in a minimally conscious state and to reflect performance in everyday life. Majerus et al. (2000) conducted a validation study of a French version of the WHIM scales (Majerus et al., 2001) showing that the WHIM scales presented good inter-rater agreement (fair to excellent inter-rater agreement was obtained for 93% of the items) and very good test-retest reliability (a correlation of .98 was obtained between WHIM scores obtained in a test and a retest session). Most importantly, the study confirmed that the WHIM was largely superior to the GCS and GLS scales for detecting subtle changes for patients emerging from the vegetative state and for patients being in a minimally conscious state: while GCS scores remained unchanged across time for many patients in these states, assessment with the WHIM permitted to detect an important number of changes in behavior and corresponding states of consciousness (see Figure 4 for an illustrative example). Furthermore, WHIM scores were more than 5 times more variable than GLS scores for patients in the minimally conscious state or patients showing a good recovery, suggesting that the WHIM is particularly sensitive for patients in the minimally conscious state. However, the study by Majerus et al. (2000) also showed that the sequence of recovery proposed by Shiel et al. (2000) is very probabilistic and lacks precision, as the proposed order of recovery could not be replicated for all items of the scale. Further studies are needed to strengthen the validity of the sequence of recovery proposed by the original version of the WHIM scales.

Shiel, A., Horn, S., Wilson, B.A., McLellan, D.L., Watson, M., and Campbell, M. (2000) The Wessex Head Injury Matrix main scale: A preliminary report on a scale to assess and monitor patients recovery after severe head injury. Clinical Rehabil, 14: 408-416.
Western Neuro Sensory Stimulation Profile (WNSSP)

Majerus, S., Van der Linden, M., and Shiel, A. (2000) Wessex Head Injury Matrix and Glasgow/Glasgow-Liège Coma Scale: A validation and comparison study. Neuropsychol Rehabil, 10: 167-184.

Majerus, S., Azouvi, P., Fontaine, A., Marlier, N., Tissier, A.-C., & Van der Linden, M. (2001) Adaptation française de la Wessex Head Injury Matric - 62 items. Unpublished test manual.


Sensory Modality Assessment and Rehabilitation Technique (SMART)

The SMART was designed to identify evidence of the patient’s awareness through a graded assessment of the level of sensory, motor and communicative responses to a structured and regulated sensory program and also as a treatment tool to guide future treatment to enhance the patient’s potential responses. The SMART comprises two components, including the informal component which consists of information from family and carers in respect of observed behaviors and information pertaining to the patients’ pre morbid interests, likes and dislikes. This component encourages active participation from families and carers, ensures that all responses seen to day-to-day activity are recorded and categorized and that the treatment is relevant to the patients’ interest, thus optimizing the opportunity for a meaningful response to stimuli. The SMART’s formal assessment comprises of the SMART Behavioral Observation Assessment and Sensory assessment and is conducted in 10 sessions within a 3-week period with an equal number of sessions in the morning and afternoon. This time frame provides frequent assessments over a short timeframe to determine whether the behavioral responses observed are both consistent and repeatable. The behavioral observation enables the assessor to become familiar with the patients’ reflexive, spontaneous and purposeful behavior during a 10-minute period prior to the commencement of the SMART Sensory Assessment.
The sensory assessment has 8 modalities including the 5 sensory modalities (visual, auditory, tactile, olfactory, and gustatory) and also motor function, functional communication and wakefulness/arousal. Consisting of 29 standardized techniques, SMART provides opportunity for patients to exhibit their full behavioral repertoire, in each of the different sensory modalities. For example, to assess the patients’ responses within the auditory modality, a range of standardized auditory stimuli are presented, including loud sound, voice and a variety of specifically selected verbal instructions. The verbal instructions are carefully selected from the patient’s behavioral repertoire exhibited as being potentially meaningful in the SMART behavioral observation, such as “raise your eyebrows”, “move your thumb”, to provide the patient with the best opportunity to follow any one or more instructions.
The SMART’s 5 point hierarchical scale is consistent and comparable across all of the sensory modalities. The five levels range from ‘no response’ (level 1) through ‘reflexive’ (level 2), ‘withdrawal’ (level 3), ‘localizing’ (level 4) and ‘discriminating’ responses (level 5). This 5-point scale relates directly to the description of Rancho Levels 1-4 (Malkmus, 1990); a consistent response (on five consecutive assessments) at SMART level 5 in any one of the sensory modalities demonstrates a meaningful response and thus indicates that the patient is showing behaviors indicative of a minimally conscious state or higher levels of function (Table).
Using the SMART requires formal training.



SMART response

Rancho levels


No response:
To any stimulus

I No response:
In deep sleep and unresponsive to stimuli


Reflex response:
To stimuli reflexive and generalized responses, i.e. startle, flexor or extensor pattern

II Generalized response:
Reacting inconsistently and non-purposefully to stimuli


Withdrawal response:
To stimuli may, for example, turn head or eyes away or withdraw limbs from stimulus

III Localized response:
Patient reacts specifically but inconsistently to stimuli


Localizing response:
To stimulus may, for example, turn head or move upper limbs towards stimuli



Differentiating response:
Patient may, for example, follow visual or auditory commands or use object appropriately

IV Confused – agitated:
And subsequent Rancho levels

Table: SMART hierarchical scale for sensory modalities and their comparison to Rancho levels (from Gill-Thwaites and Munday, 2004)

Gill-Thwaites, H. (1997). "The Sensory Modality Assessment Rehabilitation Technique--a tool for assessment and treatment of patients with severe brain injury in a vegetative state." Brain Inj 11(10): 723-34.


Western Neuro Sensory Stimulation Profile (WNSSP)


Sub-scales evaluate arousal, attention, auditory & visual comprehensive & tracking, object manipulation & communication. Attractive scale for post-comatose states but developed prior to diagnostic criteria of MCS. Does not directly derive a diagnosis from examination findings.

Ansell, B. J. and J. E. Keenan (1989). "The Western Neuro Sensory Stimulation Profile: a tool for assessing slow-to-recover head-injured patients." Arch Phys Med Rehabil 70(2): 104-8.


Coma Near Coma Scale (CNC)


This is an expansion of the upper range of the Disability Rating Scale (DRS, Rappaport et al. 1982),

Rappaport, M. (2000). The Coma/Near Coma Scale, The Center for Outcome Measurement in Brain Injury.


Levels of Cognitive Functioning


Eight-item scale with broad categories. Patients may show behaviors which are appropriate to more than one category at the same time and can change categories several times a day, e.g. ‘confused and agitated’ and ‘confused and non-agitated’.

Hagen, C., D. Malkmus and P. Durham (1987). Levels of cognitive functioning. Professional Staff Association of Rancho Los Amigos Hospital eds. Rehabilitation of the head injured adult: comprehensive physical management. C. A. Downey, Rancho Los Amigos Hospital Inc.