Standardized Measures > CRS-R
Coma Recovery Scale-Revised (CRS-R)
(Giacino et al., 2020)
General Guidelines | Training Manual | Recommended Training Program with training video | Common FAQs
Standardized neurobehavioral assessment designed for use in patients with disorders of consciousness. Used to establish a diagnosis, monitor behavioral recovery, predict outcomes, and assess treatment effectiveness. Scores guide goal writing — write goals based on what the patient is able to do, or use metrics such as number of trials to increase the challenge.
Target Population
Patients with traumatic and non-traumatic DoC who are not communicating reliably and are functioning between RLAS Levels I–IV. The CRS-R is normed for patients aged 17–79. The pediatric version can be used when assessing children between the ages of 1–5 who have not yet completed language and motor development.
Administration Considerations
Before each administration, account for the following:
Time of day. Late morning is often optimal. Avoid testing immediately after nursing care, meals, or painful procedures, which can temporarily suppress responsiveness.
Medications. Sedatives, opioids, antiepileptics, and antispasmodics can all suppress CRS-R responses and produce false-negative results. Document the patient's medication regimen at the time of each assessment. When possible, coordinate with the team to time assessments when sedation loads are lowest.
Positioning. HOB elevation to at least 30° improves arousal. Prone or flat positioning limits the visual and motor subscales and should be noted.
Pre-existing deficits. Document known sensory or motor impairments before scoring. A patient with pre-existing cortical blindness cannot be fairly scored on the visual subscale; a patient with known limb weakness or paralysis requires modification of the motor subscale approach.
Subscale Descriptions
The CRS-R is comprised of 6 subscales with hierarchically arranged items, from brainstem-mediated behaviors (lowest score) to cortically-mediated behaviors (highest score).
| Score | Behavior |
|---|---|
| Auditory Function (0–4) | |
| 4 | Consistent movement to command |
| 3 | Reproducible movement to command |
| 2 | Localization to sound |
| 1 | Auditory startle |
| 0 | None |
| Visual Function (0–5) | |
| 5 | Object recognition |
| 4 | Object localization (reaching) |
| 3 | Visual pursuit |
| 2 | Fixation |
| 1 | Visual startle |
| 0 | None |
| Motor Function (0–6) | |
| 6 | Functional object use † |
| 5 | Automatic motor response |
| 4 | Object manipulation |
| 3 | Localization to noxious stimulation |
| 2 | Flexion withdrawal |
| 1 | Abnormal posturing |
| 0 | None / flaccid |
| Oromotor / Verbal Function (0–3) | |
| 3 | Intelligible verbalization |
| 2 | Vocalization / oral movement |
| 1 | Oral reflexive movement |
| 0 | None |
| Communication (0–2) | |
| 2 | Functional: accurate (6/6 biographical questions) † |
| 1 | Non-functional: intentional |
| 0 | None |
| Arousal (0–3) | |
| 3 | Attention |
| 2 | Eye opening without stimulation |
| 1 | Eye opening with stimulation |
| 0 | Unarousable |
| † Indicates emergence from MCS (eMCS) | Maximum total score: 23 | Minimum: 0 | |
Testing Items
2 common objects (e.g., cup, comb, toothbrush)
Any object that makes a loud noise
ADL objects (e.g., toothbrush, phone)
Hand mirror
Bright colored object
Baseball-sized ball
Pencil
Tongue depressor
Scoring
Standardized based on the presence or absence of operationally-defined behavioral criteria. The behavioral response must be clearly discernible before it is scored present. A score of 10 or greater indicates a diagnosis of Minimally Conscious State (MCS) or emergence from Minimally Conscious State (eMCS). Minimum score: 0 / Maximum score: 23
Use scores to write goals. If a patient is scoring at Auditory 2 (localization to sound) and Visual 2 (fixation), your short-term goal might target Auditory 3 (reproducible movement to command) — a specific, measurable, and clinically grounded target. Scores also give you a defensible way to communicate change over time to the team and family.
Confounders matter. Sedation, analgesia, fever, intracranial hypertension, electrolyte imbalances, and recent seizure activity can all suppress CRS-R scores. Note time of day, time since last sedation, and any acute medical events when documenting. A low score in the context of a recent medical setback is different from a persistently low score in a stable patient.
When should you discontinue the CRS-R?
When all 3 of the following behaviors have been elicited concurrently, on 3 consecutive examinations conducted over 2 weeks:
Consistent movement to command (Auditory Subscale = 4)
Reliable yes-no responses (Communication Subscale = 2)
Focused attention (Arousal Subscale = 3)
Criteria for Vegetative State (VS) and Minimally Conscious State (MCS)
| CRS-R Subscale | Vegetative State | MCS | Emergence from MCS |
|---|---|---|---|
| Auditory | ≤2 AND | 3–4 OR | |
| Visual | ≤1 AND | 2–5 OR | |
| Motor | ≤2 AND | 3–5 OR | 6 OR |
| Oromotor/Verbal | ≤2 AND | 3 OR | |
| Communication | 0 | 1 | 2–3 |
| *To be designated VS, all of column 2 must be met. MCS can be achieved by receiving at least 1 column 3 score. MCS+ occurs with higher scores in motor and communication. | |||
Note. Adapted from “The JFK coma recovery scale-revised: Measurement characteristics and diagnostic utility”, by J. T. Giacino et al., 2004, Archives of Physical Medicine and Rehabilitation, 85(12), p. 2023 (doi: 10.1016/j.apmr.2004.02.033). Copyright 2004.
Arousal Facilitation Protocol
When a patient closes their eyes or stops responding during administration, do not score that subscale as absent. Instead, administer the Arousal Facilitation Protocol before re-attempting.
Initiate the protocol when:
The patient demonstrates sustained eye closure
The patient stops following commands for at least one minute despite sustained eye opening
Protocol steps:
Verbal stimulation — Call the patient's name loudly and clearly three times
Physical stimulation — Apply sternal rub or firm nailbed pressure for 3–5 seconds
Repositioning — Elevate HOB, adjust positioning, or assist to sitting if medically appropriate
Wait and retry — Allow 30 seconds, then re-administer the interrupted subscale
Re-administer the protocol any time sustained eye closure recurs or behavioral responsiveness ceases despite eye opening. If the patient remains unresponsive after all four steps, end the session and note that the protocol was required. Attempt re-administration at a different time of day.
Note: Noxious stimulation (sternal rub, nailbed pressure) should be applied with care and documented. Coordinate with nursing regarding any patient-specific contraindications.
Using the CRS-R Scores to Guide Therapy
The CRS-R is most useful when scores are interpreted at the subscale level, not just as a total. Each subscale reflects a different domain of function and points to different treatment targets.
Auditory subscale score 4 (movement to command): The patient can follow commands reliably. Shift from sensory stimulation to command-following tasks and functional activities. This score also confirms the patient is above the threshold for MCS.
Visual subscale score 5 (object recognition): The patient demonstrates cortically-mediated visual processing. Introduce choice-making with objects, visual scanning tasks, and eye gaze AAC trials.
Motor subscale score 5–6 (object manipulation / functional object use): The patient can interact purposefully with objects. Introduce ADL tasks and purposeful reaching activities. Score 6 (functional object use) meets the threshold for emergence from MCS.
Communication subscale any score above 0: The patient has some communicative behavior. Consult SLP if not already involved; begin AAC evaluation regardless of verbal status.
Total score ≥ 10: Meets threshold for MCS diagnosis. Communicate this to the team — it has significant implications for prognosis, family counseling, and goals of care conversations.
See also: CRS-R FAST for a shorter administration option when full CRS-R is not feasible in a single session.
References
Giacino, J. T., Bodien, Y. G., & Chatelle, C. (2020). CRS-R Coma Recovery Scale-Revised: Administration and scoring guidelines. https://www.tbims.org/combi/crs/CRS%20Syllabus.pdf
Giacino, J. T., Kalmar, K., & Whyte, J. (2004). The JFK Coma Recovery Scale-Revised: Measurement characteristics and diagnostic utility. Archives of Physical Medicine and Rehabilitation, 85(12), 2020–2029. https://doi.org/10.1016/j.apmr.2004.02.033