41,44-46 A detailed description of the expanded version of the GOS, as well as administration and scoring guidelines, can be found in other sources. 42,43 Several studies show improved interrater reliability of 85% and test-retest reliability of 98% when a specific structured interview is used to determine GOS category. 39,41 The interrater reliability of the scale is quite poor, in some instances only 50%. 40 The GOS is not intended to provide a detailed individual assessment of impairment and disability. In 1985 an expanded version of the GOS was developed with 8 categories to more accurately describe outcomes in the research literature by capturing subtle improvements in higher levels of functional performance. The original scale, which is still generally used today, has 5 categories: Dead, persistent vegetative state, severe disability, moderate disability, and good recovery. The Glasgow Outcome Scale (GOS) was developed in 1975 with the goal of developing a standardized language for clinical research to describe the outcomes of groups of patients with severe brain damage 39 ( Table 21-5). Overall criticisms of the GCS are its failure to include brainstem reflexes, its bias toward best motor response, and its inability to obtain a verbal score from intubated patients. A score of 9-11 indicates moderately severe brain injury, and a score of greater than or equal to 12 indicates minor injury. Total scores range from 3-15, with a score of 8 or less defining coma. The totals for all categories are summed to give the final score. Scores for eye opening range from 1-4, for best motor response from 1-6, and for best verbal response 1-5. Each category has a numerical scale assigned to specific responses. The GCS consists of three categories: Eye opening, best motor response, and best verbal response. 35 The GCS shows high interrater and intrarater reliability when used by paramedics, physicians and nurses. Originally developed for use with patients after traumatic brain injury, this scale has also proven to be a reliable predictor of outcome for patients in coma with brain damage from nontraumatic causes.
The Glasgow Coma Scale (GCS), developed in 1974, is the scale most widely used in emergency departments, community hospitals, and research literature worldwide 34 ( Table 21-4). 33 Most coma and cognitive function scales are composite scales that include measures of motor function, level of disability, and levels of arousal, attention, and cognition.
Susan Grieve, in Physical Rehabilitation, 2007 Arousal, Attention, and Cognition.Ĭoma scales and cognitive function scales have been developed with the aim of achieving standardization in determining level of consciousness for clinical research, as well as for monitoring changes during acute illness, and serving as prognostic indicators. Furthermore, in the application of the GCS to patients who have been in the ICU for an extended period of time, eye opening does not equal conscious awareness because patients with persistent vegetative state (VS) may show this and patients with seizures show spontaneous eye opening. The GCS is often insufficiently sensitive for the detection of changes in the level of consciousness in patients following head injury or with masses and risk of herniation when they are in lighter stages of impaired consciousness. Additionally, there is little difference in outcome over several different score values (e.g., between 10 and 15). It seems unlikely that all patients with specific scores ranging from 6 to 10 will be equivalent in disease severity. Furthermore, to achieve a score of 6–12, there are more than 10 simple combinations of variables, each with very different clinical profiles. Because they covary, their addition may not be valid. These are assumed to be independent variables but they are not. A theoretical disadvantage is the three-dimensional assessment: The total score is obtained by adding the values for three motor activities – eye opening, best motor response, and best verbal response. Problems with the use of the GCS arise when patients are intubated and cannot respond verbally or if the eyes are swollen shut, preventing ocular assessment. The GCS was designed for the initial assessment of patients with head injury. However, it has not been used consistently in different hospitals, and the later versions of the GCS have not been adequately tested for reliability. The Glasgow Coma Scale (GCS) ( Table 1) is almost universally used in emergency rooms and intensive care units (ICUs), and is by far the most common coma scale cited in the neurosurgical literature.
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