Neurological Sciences

, Volume 39, Issue 6, pp 1073–1077 | Cite as

Pain assessment with the revised nociception coma scale and outcomes of patients with unresponsive wakefulness syndrome: results from a pilot study

  • Sergio Bagnato
  • Cristina Boccagni
  • Antonino Sant’Angelo
  • Angelo Alito
  • Giuseppe Galardi
Original Article


The aim of this study was to evaluate whether standardized responses to nociceptive pain, assessed with the revised Nociception Coma Scale (NCS-R), were correlated with the outcomes of patients with unresponsive wakefulness syndrome (UWS) 6 months after admission to a rehabilitation department. We recruited 24 consecutive patients with UWS. Patients’ consciousness levels were assessed with the revised Coma Recovery Scale (CRS-R) at admission and 6 months later, and their CRS-R scores were correlated with the NCS-R scores at admission. Ten of the 24 patients with UWS recovered consciousness after 6 months. The NCS-R score at admission was correlated with the CRS-R score at admission (P = 0.02), but not after 6 months (P = 0.6). Patients with and without consciousness improvement after 6 months showed no significant difference in the NCS-R total score and sub-scores at admission (P values > 0.05). In conclusion, the correlation between NCS-R and CRS-R scores at admission suggests that the standardized assessment of pain parallels patients’ levels of consciousness, and may be helpful in the clinical evaluation of patients with UWS. Pain response assessed with the NCS-R was not related to the 6-month outcomes of patients with UWS.


Coma Recovery Scale revised Disorders of consciousness NCS-R Prognosis Vegetative state 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

The study abided by the Declaration of Helsinki and was approved by our Regional Ethical Review Board (Palermo 1 Ethical Committee, Palermo, Italy). Patients’ legal guardians gave their written informed consent for all procedures.


  1. 1.
    Boly M, Faymonville ME, Schnakers C, Peigneux P, Lambermont B, Phillips C, Lancellotti P, Luxen A, Lamy M, Moonen G, Maquet P, Laureys S (2008) Perception of pain in the minimally conscious state with PET activation: an observational study. Lancet Neurol 7:1013–1020CrossRefPubMedGoogle Scholar
  2. 2.
    de Tommaso M, Navarro J, Lanzillotti C, Ricci K, Buonocunto F, Livrea P, Lancioni GE (2015) Cortical responses to salient nociceptive and not nociceptive stimuli in vegetative and minimal conscious state. Front Hum Neurosci 29(9):17Google Scholar
  3. 3.
    Naro A, Leo A, Cannavò A, Buda A, Bramanti P, Calabrò RS (2016) Do unresponsive wakefulness syndrome patients feel pain? Role of laser-evoked potential-induced gamma-band oscillations in detecting cortical pain processing. Neuroscience 317:141–148CrossRefPubMedGoogle Scholar
  4. 4.
    Garcia-Larrea L, Bastuji H (2018) Pain and consciousness. Prog Neuro-Psychopharmacol Biol Psychiatry.
  5. 5.
    Chatelle C, Majerus S, Whyte J, Laureys S, Schnakers C (2012) A sensitive scale to assess nociceptive pain in patients with disorders of consciousness. J Neurol Neurosurg Psychiatry 83:1233–1237CrossRefPubMedGoogle Scholar
  6. 6.
    Chatelle C, Thibaut A, Bruno MA, Boly M, Bernard C, Hustinx R, Schnakers C, Laureys S (2014) Nociception coma scale-revised scores correlate with metabolism in the anterior cingulate cortex. Neurorehabil Neural Repair 28:149–152CrossRefPubMedGoogle Scholar
  7. 7.
    Bagnato S, Boccagni C, Sant’angelo A, Fingelkurts AA, Fingelkurts AA, Galardi G (2013) Emerging from an unresponsive wakefulness syndrome: brain plasticity has to cross a threshold level. Neurosci Biobehav Rev 37:2721–2736CrossRefPubMedGoogle Scholar
  8. 8.
    Giacino JT, Kalmar K, Whyte J (2004) The JFK coma recovery scale-revised: measurement characteristics and diagnostic utility. Arch Phys Med Rehabil 85:2020–2029CrossRefPubMedGoogle Scholar
  9. 9.
    Royal College of Physicians (2016) Prolonged disorders of consciousness: National clinical guidelines. R.C.P., LondonGoogle Scholar
  10. 10.
    Giacino JT, Ashwal S, Childs N, Cranford R, Jennett B, Katz DI, Kelly JP, Rosenberg JH, Whyte J, Zafonte RD, Zasler ND (2002) The minimally conscious state. Definition and diagnostic criteria. Neurology 58:349–353CrossRefPubMedGoogle Scholar
  11. 11.
    Gerrard P, Zafonte R, Giacino JT (2014) Coma Recovery Scale-Revised: evidentiary support for hierarchical grading of level of consciousness. Arch Phys Med Rehabil 95:2335–2341CrossRefPubMedGoogle Scholar
  12. 12.
    Fenton BW, Shih E, Zolton J (2015) The neurobiology of pain perception in normal and persistent pain. Pain Manag 5:297–317CrossRefPubMedGoogle Scholar
  13. 13.
    Koch C, Massimini M, Boly M, Tononi G (2016) Neural correlates of consciousness: progress and problems. Nat Rev Neurosci 17:307–321CrossRefPubMedGoogle Scholar
  14. 14.
    Bagnato S, Boccagni C, Sant’Angelo A, Fingelkurts AA, Fingelkurts AA, Galardi G (2017) Longitudinal assessment of clinical signs of recovery in patients with unresponsive wakefulness syndrome after traumatic or nontraumatic brain injury. J Neurotrauma 34:535–539CrossRefPubMedGoogle Scholar
  15. 15.
    Nakase-Richardson R, Whyte J, Giacino JT, Pavawalla S, Barnett SD, Yablon SA, Sherer M, Kalmar K, Hammond FM, Greenwald B, Horn LJ, Seel R, McCarthy M, Tran J, Walker WC (2012) Longitudinal outcome of patients with disordered consciousness in the NIDRR TBI Model Systems Programs. J Neurotrauma 29:59–65CrossRefPubMedGoogle Scholar
  16. 16.
    Estraneo A, Moretta P, Loreto V, Lanzillo B, Santoro L, Trojano L (2010) Late recovery after traumatic, anoxic, or hemorrhagic long-lasting vegetative state. Neurology 75:239–245CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Italia S.r.l., part of Springer Nature 2018

Authors and Affiliations

  1. 1.Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries, Rehabilitation DepartmentFondazione Istituto Giuseppe GiglioCefalùItaly

Personalised recommendations