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Reply: Does the JFK revised coma recovery scale complement the FOUR score?

The FOUR score (Full Outline of Unresponsiveness) has been well received in and outside the United States and has been implemented at the Mayo Clinic Saint Mary’s Hospital. What is notable is that the nursing staff has enthusiastically embraced the new coma scale. Studies on its usefulness outside the boundaries of the NeurologicalNeurosurgical Intensive Care Unit are under way. The FOUR score has been developed to assess the depth of coma in a more detailed manner than the Glasgow Coma Scale. The FOUR score was not devised to assess long-term severely disabled or permanently unconscious patients as much as the JFK revised coma recovery scale (JFK CRS-R) was not devised to assess acutely comatose patients. The JFK CRS-R lacks important parts of the neurological examination, tests six components, and requires considerable time of observation to be certain of the behavioral responses of the patient. The FOUR score was also not developed to diagnose a vegetative or minimally conscious state. That requires a comprehensive neurological evaluation and observations over time. Nonetheless, Schnakers and colleagues note that the FOUR score recognizes important clinical components of these conditions when tested in a new set of patients. We believe the answer to their question is a tentative yes. Does the JKFCRS-R complement the FOUR score? In patients who remain unconscious or show possible early signs of awareness, the JFK CRS-R may have additional value in differentiating vegetative from minimally conscious states. The JFK CRS-R may identify visual fixation, but that is a difficult test that requires careful and prolonged observation and is a clinical sign that has to be differentiated from a visual orienting reflex in vegetative state. Visual fixation may also occur in akinetic mutism, and thus may not indicate emergence from a comatose state. Visual fixation for those reasons has not been included in the FOUR score. Moreover the JKF CRS-R will have to be validated in large group of patients using physicians and nursing staff who manage acutely comatose or stuporous patients as raters. However, Schnakers and colleagues’ study is interesting and suggests that perhaps a FOUR score assessment followed by a JFK CRS-R assessment (if warranted) may be a useful combination in certain instances. We are pleased that the rehabilitation community has an interest in the FOUR score. Cross-pollination of scales may be useful, and the FOUR score is currently tested in the rehabilitation setting in our institution. Divisions of Critical Care Neurology and Biostatistics, Mayo Clinic College of Medicine, Rochester, MN, Ajantha Clinic, Cochin, Kerala, India, and Collaborative Health Studies Coordinating Center, University of Washington, Seattle, WA