In 1974, leading neuroscientist Graham Teasdale co-created the Glasgow Coma Scale (GCS) while at the Institute of Neurological Sciences in Glasgow. This scale has since been used to assess coma and impaired consciousness in patients who have had a brain injury.
The scale is used to describe variations in a patient’s eye, motor, and verbal responses. Each feature is assigned numerical scores depending on the quality of the response, and total scores range from three, which is a deep coma, to 15, which is full consciousness.
The GCS is used in clinics all around the world by physicians, nurses, and emergency medical technicians; and is also applied more widely in other, more complex systems that are used in assessing acute brain damage.
However, all three features of the GCS can’t always be determined in patients. Most commonly, the verbal response can’t be tested, as it’s not possible to determine this response in patients with severe brain injury who are intubated.
When the verbal score cannot be measured, the GCS can still be used in routine assessment and communication about a patient’s condition.
“The GCS should be reported in its component parts, so there is still useful information in the motor and eye components, and the verbal score can simply be reported as not testable,” Paul Brenan, senior clinical lecturer in neurosurgery at the University of Edinburgh says.
“The missing verbal score is problematic, though ,when determining the GCS sum score (eyes + verbal + motor). The sum score is used in clinical prognostic tools, such as the GCS -pupils score, so until now, missing verbal data has prevented clinicians from using these tools.”
But now, Teasdale and Brennan, along with Gordon Murray at the University of Edinburgh, have created a tool to use to assess impaired consciousness when the verbal component of the GCS is missing.
The researchers first examined a database of GCS assessments, and found that the verbal component of GCS was missing in 12,000 patients with traumatic brain injury (TBI), which made up 11 per cent of GCS assessments. These verbal scores were most often missing in patients with low eye and motor scores.
Using GCS data recorded in a database of 54,000 patients, the researchers calculated the distribution of verbal scores for each combination of eye score and motor score. They then combined GCS eye and motor scores into EM scores, and determined the distribution of verbal scores for each EM score. Based on this, they identified a verbal score that clinicians could impute for every EM score.
“Without the verbal component of the GCS, the GCS sum score (eyes + Verbal + motor) cannot be determined, so we developed this imputation tool to enable clinicians to benefit from these prognostic tools for decision making in patients with the most severe brain injuries, where the verbal score is not testable,” Brennan says.
To test these imputed verbal scores, the researchers substituted imputed verbal scores for actual verbal scores within the framework of prognostic charts, which the authors had previously developed.
These charts take into account the total GCS score, pupil response, age of the patient, and findings of abnormalities. The charts provide predictions about patient outcomes, and are designed to help clinicians make decisions and communicate across teams.
The authors outline in their paper, ‘A practical method for dealing with missing Glasgow Coma Scale verbal component scores,’ published in the Journal of Neurosurgery, that they found that the information gleaned from imputing verbal scores according to each EM score was similar to the variations between precise eye and motor scores, and from full information on verbal, eye, and motor responses.
Imputing verbal scores doesn’t add new information, but allows clinicians to use prediction and prognostic models by filling in verbal data needed for those systems to work.
“We have developed several tools related to the GCS that enhance its ease of use and clinical application, including the GCS Aid, the GCS-pupils score and the GCS pupils Age CT prognostic charts,” Brennan tells NR Times.
“These have been designed to address specific needs. For example, the GCS Aid was developed to support training in assessment of the GCS and to enhance reproducibility of assessment. The GCS pupils score and prognostic charts provide a simple but robust prognostic tool that can be used in the clinic.”
“Prognostic scores are helpful for clinicians to get a reliable prediction of patient outcome, to inform clinical decision-making and to support communication with a patient’s family.
“We know from previous research that clinicians can tend to predict overly pessimistic outcomes for patients, particularly those with severe brain injuries, so these prediction models are designed to prevent that. With our imputation tool, the sum score can be determined and prognostic models used in real-time in the clinic.”
The researchers believe that being able to add verbal scores will help clinicians quickly determine the severity of acute brain injury and estimate patient outcomes.
“We know from the enquires we get and from the number of downloads of materials from our website, that these are very popular and are having a positive impact on clinical care around the world.
“We are confident this missing verbal score imputation tool will be just as positively received,” Brennan says.
Has UEFA done enough to protect player safety at Euro 2020?
The collapse of Denmark’s Christian Eriksen due to a cardiac arrest during his team’s opening game at Euro 2020 shocked football fans worldwide and raised many questions about player safety. Here, sports disputes lawyer Barrington Atkins examines football authorities’ approach to the safety of players and asks whether UEFA has done enough to protect those competing at Euro 2020
Concussion safety was meant to be at the forefront of the Euro 2020 finals.
All 24 teams committed to following the recommendations of the Union of European Football Associations (UEFA) Concussion Charter, which was a commitment to player welfare and player safety.
All 24 teams agreed to implement the serious measures recommended by UEFA to provide care for players who experience concussions or have injuries on the pitch. The message of the Charter was clear: if a player is suspected of concussion, they must be removed from the field of play.
UEFA’s focus on concussion follows a growing awareness of the greater risk footballers’ face of neurodegenerative diseases from head injuries. Research commissioned by the Football Association and the Professional Footballers’ Association found that ex-professional footballers are three and a half times more likely to die from dementia than people of the same age range in the general population.
The concussion and fractured skull sustained by Wolves’ Raul Jimenez following a collision with Arsenal’s David Luiz in November 2020 was the final straw that led to the implementation of the concussion substitutes rule in the Premier League. This new rule states that if a player has clear symptoms of concussion or video provides clear evidence of concussion, his team will be permitted to replace him with an additional substitute.
On 21 February 2021, Rob Holding became the first Premier League player to be replaced under the rule. The protection the rule provided to player safety was instantly demonstrated as Holding was confirmed to have concussion the following day.
Despite the proven benefits, UEFA decided against approving the concussion substitutes rule for the Euro 2020 finals. The injuries football fans have witnessed during the European tournament have undoubtedly challenged UEFA’s decision and called into question whether the Concussion Charter is effective enough for player safety.
The first incident occurred when France’s Benjamin Pavard sustained a head injury following a collision with Germany’s Robin Gosens. Pavard received treatment for several minutes before being given the green light to continue playing. Pavard later revealed that he was knocked out for 10 to 15 seconds. Controversially, UEFA confirmed that the correct concussion protocols were followed.
Only six days later, Austria’s Christoph Baumgartner received a blow to the head, went back on the pitch and was then substituted. His coach later admitted that Baumgartner had been experiencing dizziness.
Russia’s Danila was the third player in the tournament to collapse to the ground following a head injury. He was cleared to play on but was withdrawn at half time. These incidents demonstrate that football authorities need to do more to protect players’ health.
Cardiac conditions too are highly significant here, being the leading cause of death in professional footballers. Data has revealed a prevalence of sudden cardiac death of seven in 100,000 football players.
Quick application of a defibrillator can improve a patient’s survival by 75 per cent. However, when Cameroon’s Marc-Vivien Foé collapsed during the 2003 Confederations Cup in France, it took six minutes before attempts to restart his heart began. The lack of awareness of the need for speedy care contributed to Foé’s death, but the incident spurred football authorities to implement changes to reduce the risk of cardiac arrest on the field.
The English Football Association has now increased screening frequency so that players are tested between the ages of 14 and 25. For incidents where cardiac conditions slip through the net, sporting organisations have pitch-side defibrillators and medical staff trained in CPR to help resuscitate a player if they suffer a cardiac arrest.
Player safety was brought to the forefront on 12 June 2021 when Christian Eriksen experienced a cardiac arrest during Denmark’s game against Finland. Thankfully, football authorities’ understanding of the need for urgent medical attention in cardiac emergencies helped save Eriksen’s life.
The Euro 2020 finals have shown that football authorities need to take further urgent action to protect player welfare and player safety. However, as Christian Erikson’s recovery happily shows, player safety can be achieved when football authorities apply the correct protocols and have appropriate medical equipment in place.
Life after lockdown – what comes next?
As we prepare to emerge from lockdown in less than two weeks, attention is turning to what the ‘new normal’ will be like. Margreet Wittink at Renovo Care shares some reflections from the pandemic and thoughts on what may lie ahead
The 19th of July 2021. More than just any date.
We all have certain dates that are important to us, like birthdays and anniversary dates. However, this year we have been governed by dates set by the government trying to get back to a normal life post-COVID.
We seemed to be going in the right direction but then the Delta variant presented itself. The infection rates started to go up again and continue to rise but with far less hospital admissions. Opinion seems to be divided on whether we need to remain cautious and wait or return to normal life whatever it may bring. The British Medical Association is calling for caution and is asking for ongoing use of face masks and new ventilation standards.
The 19th of July 2021 will mark the fourth and final stage of lifting lockdown in England. It makes me reflect on the period since March 23 2020 when the first lockdown started.
A birthday present my son didn’t want. Being an essential worker continuing to drive to Hollanden Park Hospital on an empty M25 and A21, seeing a banner thanking those who continued to work which I appreciated so much. Taking staff temperatures which was thought to be needed for just three months but lasted so much longer.
The absolute low of the period? Losing a much loved colleague and being unable to pay the traditional respects. But never losing sight of the most important aspect of our work; keeping our patients at Renovo Care safe.
Will life get back to normal? But what is normal? Hasn’t COVID shown us all that life can change dramatically in a short period of time?
That is something that is all too familiar to our patients who come to Renovo Care for their neurological rehabilitation following stroke, traumatic brain injury, Guillain Barre Syndrome to name a few of the diagnosis we treat.
We know how important family support is to our patients and how difficult it has been for them to be at our hospital without seeing their loved ones regularly in person. The use of Zoom and Microsoft Teams has given us a way to be in touch and being able to share therapy sessions, but it has been a poor substitute.
Recently we have been able to allow family members, who take on a carer role, in again nearer the discharge date to work together to prepare for a smooth transfer from Renovo Care to home. This has made such a difference to them to know what can be expected when their loved one comes home following a major event that changed their life.
Normality. What will it look like? No more face masks or social distancing? Are we ready for it?
I think that staff and patients alike will welcome staff not having to wear masks. When one of our patients left, he actually asked one of the therapists if she could remove her mask for a moment so he could see what she looked like.
Not wearing face masks will allow us all to see facial expressions again which is so important for communicating with each other. Hats off to our speech and language therapists who had to adapt their way of working around the COVID restrictions.
Will our visiting return to the way it used to be? Successful neurorehabilitation requires 24-hour support of all the parties involved which includes family. Being able to get hugs, to be held and to be seen face-to-face by your loved ones when you are working hard to regain your independence is so important to keep the focus on the goals they are trying to achieve.
It will require a transition from staff as we’ve had a dedicated visitors’ areas away from our patient rooms and rehab facilities for such a long time now, that it will be a novelty to have visitors back in these areas again.
The 19th of July 2021; the final stage of England’s COVID lockdown roadmap. The final review will happen on the 12th of July following analysis of the latest data. The Delta variant is on the rise but so are the vaccination numbers. Renovo Care has had a successful vaccination programme for staff and patients.
It looks like it is really happening and here at Renovo Care we will be ready for whatever comes and will make sure that our patient best interests are at the heart of what we do.
- Margreet Wittink is head of therapies/ lead occupational therapist, at Renovo Care Group’s Hollanden Park Hospital
‘Like bees collaborating in a hive, achievements in rehab should be shared’
Achievement in rehabilitation should be shared and celebrated with supporters to help sustain and encourage progress, says Lisa Beaumont, whose own ten-year recovery from stroke continues with the support of family, friends and therapists
Rehabilitation works best when it is not undertaken in isolation.
Over the past month, I have been thrilled by the progress that I have made towards my goal to walk without a stick, my posture has improved significantly during lockdown and I have enjoyed walking in the garden in June’s sunshine.
My progress has reminded me of the saying, “it takes a village to raise a child”. I would like to adapt that expression to become: “it takes a village to deliver successful rehabilitation, many people have important roles to play”.
Just like bees cooperate in a productive hive, it is helpful for the patient to share their achievements with supporters, because their affirmation gives encouragement for renewed progress.
From the outset, I have been very fortunate that I’ve had the support from family, friends and therapists throughout my ten year recovery.
An important feature of the rehabilitation platform Neuro ProActive is that it makes it easy to share a patient’s progress with each of the key players in their recovery programme. For me, it looks like this:
My team is my neuro-physiotherapist, Jane Cast (neurorehabkent.com)
My representatives are my carers and sister. It is a bonus that I can keep everyone who is in my support bubble informed about my progress privately, by sharing photos and videos securely within the fully-encrypted platform.
Neuro ProActive is also a key player. Recently named as a Strategic Partner for UKABIF, we are now also part of the Criminal Justice Acquired Brain Injury Interest Group.
Prepared with assistance from Paige Gravenell (neurorehabkent.com)
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