Skip to main content
SpringerLink
Log in

Assessment of responsiveness in acute cerebral disorders

A multicentre study on the Reaction Level Scale (RLS 85)

  • Clinical Articles
  • Published:
Acta Neurochirurgica Aims and scope Submit manuscript

Summary

A new scale for assessment of overall responsiveness, the Reaction Level Scale (RLS 85), which has been shown to have better reliability than the Glasgow Coma Scale (GCS), has been tested in four neurosurgical departments regarding inter-observer agreement and coveragei. e. the proportion of patients that could be assessed by the scale. In a carefully designed study 51 observers pairwise performed 164 tests on 88 patients. Reliability was studied by the Kappa method, which is defined as inter-observer agreement corrected for agreement by chance. The inter-observer agreement measured as overall Kappa was good (K=0.69 ±0.05) and there were no significant differences between the departments, professional categories or aetiologies. Regarding the separate RLS 85 levels the Kappa values were above 0.65, except for withdrawing (K=0.51) and flexor responses (K=0.55). There was good inter-observer agreement on coma (K=0.71).

In conclusion, the RLS 85 proved to be easily learnt, it showed full coverage without pseudoscoring, and it was used in a consistent way by doctors, nurses and assistant nurses of four different neurosurgical departments in two Scandinavian countries.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Abreviated Injury Scale 1985 Revision. American Association for Automotive Medicine, Arlington Heights IL 60005, USA

  2. Bates D, Caronna JJ, Cartlidge NEF, Knill-Jones RP, Levy DE, Shaw DA, Plum F (1977) A prospective study of nontraumatic coma: Methods and Results in 310 patients. Ann Neurol 2: 211–220

    PubMed  Google Scholar 

  3. van der Berge JH, Schouten HJA, Boomstra S, van Drunen Littel S, Braakman R (1979) Interobserver agreement in assessment of ocular signs in coma. J Neurol Neurosurg Psychiatry 42: 1163–1168

    PubMed  Google Scholar 

  4. Bishop YMM, Fienberg SE, Holland PW (1975) Discrete multivariate analysis. MIT Press, Cambridge Mass, pp 395–397

    Google Scholar 

  5. Born JD, Albert A, Hans P, Bonnal J (1985) Relative prognostic value of best motor response and brain stem reflexes in patients with severe head injury. Neurosurgery 16: 595–401

    PubMed  Google Scholar 

  6. Braakman R, Avezaat CJJ, Maas AIR, Roel M, Schouten HJA (1977) Interobserver agreement in the assessment of the motor response of the Glasgow Coma Scale. Clin Neurol Neurosurg 80: 100–106

    PubMed  Google Scholar 

  7. Braakman R, Gelpke GJ, Habbema JDF, Maas AIR, Minderhoud JM (1980) Systematic selection of prognostic features in patients with severe head injury. Neurosurgery 6: 362–370

    PubMed  Google Scholar 

  8. Braakman R, Habbema JDF, Gelpke FJ (1982) Comparability of Data. In: Grossman RG, Gildenberg PL (eds) Head injury: basic and clinical aspects. Raven Press, New York, pp 189–194

    Google Scholar 

  9. Bradley JV (1968) Distribution free statistical tests. Prentice-Hall, New York, pp 76–78

    Google Scholar 

  10. Brihaye J, Frowein RA, Lindgren S, Loew F, Stroobrandt G (1978) Report on the Meeting of the W.F.N.S. Neuro-Traumatology Committee, Brussels, 19–23 September 1976. Acta Neurochir (Wien) 40: 181–186

    Google Scholar 

  11. Cohen JA (1960) A coefficient of agreement for nominal scales. Educ Psychol Measurem 20: 37–46

    Google Scholar 

  12. Eisenberg HM (1985) Outcome after head injury: General considerations and neurobehavioral recovery. Part I: General considerations. In: Becker DP, Povlishock JT (eds) Central nervous system trauma status report 1985, NIH, Washington, pp 271–280

    Google Scholar 

  13. Fleiss JL (1971) Measuring nominal scale agreement among many raters. Psychol Bull 76: 378–382

    Google Scholar 

  14. Gennarelli TA, Spielman GM, Langfitt TW, Gildenberg PL, Harrington T, Jane JA, Marshall LF, Miller JD, Pitts LH (1982) Influence of the type of intracranial lesion on outcome from severe head injury. J Neurosurg 56: 26–32

    PubMed  Google Scholar 

  15. Godfrey K (1985) Comparing the means of several groups. N Engl J Med 313: 1450–1456

    PubMed  Google Scholar 

  16. Guildford JP (1975) Psychometric Methods. Tata McGraw-Hill edition, Haryana, pp 278–280

    Google Scholar 

  17. Holmgren E, Lindgren S, Starmark J-E, Stålhammar D (1985) Assessment of coma and severity of head injuries in Scandinavian countries. Acta Neurochir (Wien) 78: 73–74

    Google Scholar 

  18. International Classification of Diseases. Manual of the International Statistical Classification of Diseases, Injuries and Causes of Death (1977) World Health Organization, Geneva

  19. Jennett B, Teasdale G (1977) Aspects of coma after severe head injury. Lancet i: 878–881

    Google Scholar 

  20. Jennett B, Teasdale G, Braakman R, Minderhoud J, Heiden J, Kurze T (1979) Prognosis of patients with severe head injury. Neurosurgery 4: 283–289

    PubMed  Google Scholar 

  21. Langfitt TW (1978) Measuring the outcome from head injuries. J Neurosurg 48: 673–678

    PubMed  Google Scholar 

  22. Langfitt TW, Gennarelli TA (1982) A holistic view of head injury including a new clinical classification. In: Grossman RG, Gildenberg PL (eds) Head injury: basic and clinical aspects. Raven Press, New York, pp 1–14

    Google Scholar 

  23. Levy DE, Bates D, Caronna JJ, Cartlidge NEF, Knill-Jones RP, Lapinski RH, Singer BH, Shaw DA, Plum F (1981) Prognosis in nontraumatic coma. Ann Intern Med 94: 293–301

    PubMed  Google Scholar 

  24. Lindsay KW, Teasdale G, Knill-Jones RP (1982) Observer variability in grading patients with subarachnoidal hemorrhage. J Neurosurg 56: 628–633

    PubMed  Google Scholar 

  25. Lindsay KW, Teasdale GM, Knill-Jones RP (1983) Observer variability in assessing the clinical features of subarachnoid hemorrhage. J Neurosurg 58: 57–62

    PubMed  Google Scholar 

  26. Lindström S (1986) Experimental animal physiology related to brain stem control of wakefulness. In Lindgren S (ed) Modern concepts in neurotraumatology. Acta Neurochir (Wien) [Suppl] 36: 81–85

  27. Maas AIR, Braakman R, Schouten HJA, Minderhoud JM, van Zomeren AH (1983) Agreement between physicians on assessment of outcome following severe head injury. J Neurosurg 58: 321–325

    PubMed  Google Scholar 

  28. Marshall LF, Sadler GR, Klauber MR, Bowers SA (1982) Head Injuries: How can we compare outcomes? In: Grossman RG, Gildenberg PL (eds) Head injury: basic and clinical aspects. Raven Press, New York, pp 195–201

    Google Scholar 

  29. Miller JD, Teasdale GM (1985) Clinical trials for assessing treatment for severe head injury. In: Becker DP, Povlishock JT (eds) Central nervous system trauma status report 1985, NIH. Washington, pp 17–32

    Google Scholar 

  30. Plum F (1975) State of consciousness scoring system: Comment. J Neurosurg 43: 251–252

    PubMed  Google Scholar 

  31. Plum F, Posner JB (1980) Diagnosis of stupor and coma, 3rd edition. FA Davies Company, Philadelphia

    Google Scholar 

  32. Price DJ (1986) Factors restricting the use of coma scales. In: Lindgren S (ed) Modern concepts in neurotraumatology. Acta Neurochir (Wien) [Suppl] 36: 106–111

  33. Price DJ, Marsden AK (1982) A practical coma scale for monitoring head injuries. In: Wilson, Marsden (eds) Care of the acutely ill and injured. J Wiley and Sons, Ltd

  34. Stanczak DE, White III JG, Gouview WD, Moehle KA, Daniel M, Novack T, Long CJ (1984) Assessment of level of consciousness following severe neurological insult. J Neurosurg 60: 955–960

    PubMed  Google Scholar 

  35. Starmark J-E, Heath A (1987) Severity grading in self-poisoning. Submitted for publication

  36. Starmark J-E, Stålhammar D, Holmgren E (1987) Assessment of responsiveness in acute cerebral disorders. A critical survey of current reporting with special reference to the Glasgow Coma Scale. RLS85. To be published

  37. Starmark J-E, Stålhammar D, Holmgren E, Rosander B (1987) Assessment of responsiveness in acute cerebral disorders. The Glasgow Coma Scale and the Reaction Level Scale (RLS85)—a comparison. To be published

  38. Starmark J-E, Stålhammar D, Holmgren E, Olanders S, Rosander B (1987) Assessment of Responsiveness in Acute Cerebral Disorders. Interobserver Variability in the Glasgow Coma Scale Sum Score. To be published.

  39. Stålhammar D, Starmark J-E (1986) Assessment of responsiveness in head injury patients. In: Lindgren S (ed) Modern concepts of neurotraumatology. Acta Neurochir (Wien) [Suppl] 36: 91–94

  40. Sugiura K, Muraoka K, Chishiki T, Baba M (1983) The Edinburgh—2 Coma Scale: A new scale for assessing impaired consciousness. Neurosurgery 12: 411–415

    PubMed  Google Scholar 

  41. Teasdale G, Jennett B (1974) Assessment of coma and impaired consciousness. A practical scale. Lancet ii: 81–84

    Google Scholar 

  42. Teasdale G, Jennett B (1976) Assessment and prognosis of coma after head injury. Acta Neurochir (Wien) 34: 45–55

    Google Scholar 

  43. Teasdale G, Knill-Jones R, van der Sande J (1978) Observer variability in assessing impaired consciousness and coma. J Neurol Neurosurg Psychiatry 41: 603–610

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Neurosurgery, University of Göteborg, Sahlgren's Hospital, Göteborg, Sweden

    D. Stålhammar, J. -E. Starmark & E. Holmgren

  2. Department of Psychiatry III, University of Göteborg, Lillhagen's Hospital, Göteborg, Sweden

    J. -E. Starmark

  3. The Swedish Foundation for Occupational Health and Safety for State Employees, Göteborg, Sweden

    E. Holmgren

  4. Department of Neurosurgery, University of Uppsala, Akademiska Hospital, Uppsala, Sweden

    N. Eriksson

  5. Department of Neurosurgery, University of Lund, Lund, Sweden

    C. -H. Nordström

  6. Rigshospitalet, University Clinic of Neurosurgery, Copenhagen, Denmark

    O. Fedders

  7. The Gothenburg Centre for Applied Mathematics, Chalmers University of Technology, University of Göteborg, Sweden

    B. Rosander

Authors
  1. D. Stålhammar
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. J. -E. Starmark
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. E. Holmgren
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. N. Eriksson
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. C. -H. Nordström
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. O. Fedders
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. B. Rosander
    View author publications

    You can also search for this author in PubMed Google Scholar

Rights and permissions

Reprints and permissions

About this article

Cite this article

Stålhammar, D., Starmark, J.E., Holmgren, E. et al. Assessment of responsiveness in acute cerebral disorders. Acta neurochir 90, 73–80 (1988). https://doi.org/10.1007/BF01560558

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF01560558

Keywords

Search

Navigation