LAUSR

Emerging evidence suggests that up to 80% of hospitalized patients with coronavirus disease 2019 (COVID-19) develop neurological symptoms [1]. The most severely affected patients experience a disorder of consciousness (DoC), which may persist after cessation of intravenous sedation and mechanical ventilation [2]. Preliminary data suggest that recovery of consciousness is possible in these patients, even after weeks of unresponsiveness [3–5]. Yet the data are limited and susceptible to reporting bias; thus, the natural history of recovery in patients with COVID-19 DoC remains unknown. In this setting of ongoing uncertainty, clinicians and families face decisions about continuation of life-sustaining therapy and the utility of rehabilitative care for patients with COVID19 DoC [6]. In this issue of Neurocritical Care, Gurin and colleagues [7] shed new light on the natural history of recovery and optimal rehabilitative care for patients with COVID-19 DoC. The authors report results from 21 patients who participated in a comprehensive rehabilitation program developed for patients with COVID-19 DoC in the intensive care unit (ICU). This ICU rehabilitation program, implemented during the spring 2020 COVID-19 surge in New York City, included multidisciplinary consultative care specialists from neurology, physiatry, physical therapy, occupational therapy, and speech–language therapy. Patients were treated with multimodal sensory stimulation, early mobilization, and pharmacologic stimulants. Crucially, the rehabilitation program also included serial behavioral assessments with the Coma Recovery Scale-Revised (CRS-R) [8], which were performed by a team of 15 physical, occupational, and speech–language therapists; results informed communication between members of the interdisciplinary team about prognosis and discharge planning. The key finding of the study is that early rehabilitation and assessment of consciousness by using a standardized behavioral scale was feasible to implement in the ICU for all 21 patients with COVID-19 DoC. The CRS-R detected behavioral signs of consciousness in 12 patients (57%) prior to hospital discharge, although the investigators relied on the CRS-R total score, which is less specific for detecting consciousness than the subscale scores [9]. Behavioral assessment for critically ill patients is typically performed with the Glasgow Coma Scale, but the CRS-R increases the sensitivity for detecting consciousness by up to 40% [10] because of assessment of additional behaviors, such as gaze-tracking, and an emphasis on maximizing arousal prior to evaluation. The CRS-R was endorsed by a 2018 multi-society guideline [11] and received the strongest recommendation from an American Congress of Rehabilitation Medicine task force on the basis of its psychometric properties for detecting consciousness in patients with subacute to chronic DoC [12]. Accordingly, the CRS-R is used in rehabilitation settings worldwide, but the time required to complete a CRS-R assessment (up to 45 min) has historically limited its use in the ICU, where comprehensive behavioral assessments may not be feasible. In this context, it is noteworthy that a median of six CRS-R assessments were performed in the 21 patients with COVID-19 DoC, exceeding the recommended *Correspondence: [email protected] 1 Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street ‐ Suite 300, Boston, MA, USA Full list of author information is available at the end of the article