Cross-Cultural Adaptation and Validation of the Greek Version of the “Full Outline of Unresponsiveness Score”: A Prospective Observational Clinimetric Study in Neurosurgical Patients

Abstract

Background: The Full Outline of Unresponsiveness (FOUR) score is a clinical instrument for the assessment of consciousness which is gradually gaining ground in clinical practice, as it incorporates more complete neurological information than the Glasgow Coma Scale (GCS). The main objectives of the current study were the following: (1) translate and cross-culturally adapt the FOUR score into Greek; (2) evaluate its clinimetric properties, including interrater reliability, internal consistency, and construct validity; and (3) evaluate the reliability of assessments among health care professionals with different levels of experience and training. Methods:The FOUR score was initially translated into Greek. Next, patients with neurosurgical pathologies in need of consciousness monitoring were independently assessed with the GCS and FOUR score within one hour by four raters who had different levels of experience and training (two board-certified neurosurgeons, a neurosurgery resident, and a registered nurse). Interrater reliability, internal consistency, and construct validity were evaluated for the scales using weighted Cohen's κ (κ w ) and intraclass correlation coefficients (ICC), Cronbach's α and Spearman's ρ values, respectively. Results: A total of 408 assessments were performed for 99 patients. The interrater reliability was excellent for both the FOUR score (ICC = 0.941) and GCS (ICC = 0.936). The values of κ w exceeded 0.90 for all pairs, suggesting that the FOUR score can be reliably applied by raters with varying experience. Among the scales' components, FOUR score's brainstem and respiratory items showed the lowest, yet high enough (κ w > 0.60), level of agreement. The interrater reliability remained excellent (κ w > 0.85, ICC > 0.90) for all diagnosis and age groups, with a trend toward higher FOUR score values in the most severe cases (ICC = 0.813 vs. 0.723). Both the FOUR score and GCS showed high internal consistency (Cronbach's α > 0.70 for all occasions). The FOUR score correlated strongly with GCS (Spearman's ρ > 0.90 for all raters), suggesting high construct validity.

A escala Full Outline Of UnResponsiveness e seus desafios para implantação: revisão integrativa

“…Além disso, um estudo de tradução realizado na Grécia, refere que apesar da escala FOUR ser considerada de fácil aplicação e memorização, ela requer treinamento, assim, a falta de prática e conhecimento acerca dessa ferramenta pode ser considerada como uma barreira a respeito da sua adesão (ANESTIS DM, et al, 2022). Ainda, a baixa adesão a essa escala pode ser explicada por um estudo realizado na Turquia pelo fato de evidenciarem que a escala FOUR não é superior a ECG, o que pode induzir a não utilizarem a escala FOUR em substituição a ECG (EKEN C, et al, 2009), no entanto, estudos destacam que a escala FOUR é uma ferramenta valiosa, principalmente, no que se refere a avaliação dos componentes oculares, motores e respiratórios, demonstrando a sua relevância clínica e a importância de sua adesão (ANESTIS DM, et al, 2022;EKEN C, et al, 2009). Destaca-se como limitação deste estudo, a falta de clareza e exploração dos estudos acerca da temática, como também, a escassez de manuscritos, em âmbito nacional, o que dificulta compreender os desafios da aplicação da escala FOUR na realidade brasileira, evidenciando a necessidade de desenvolver novos estudos metodologicamente bem delineados capazes de propor condutas que minimizem os desafios para a implantação desta escala.…”

Clinimetric study and review of the Reaction Level Scale

“…The reliability of the RLS among raters with different scientific background was high, even for the less experienced ones, but lower than the GCS and the FOUR Score. 19,28 It should be mentioned though that κ statistics are affected by the number of categories, since scales containing more categories have an advantage. 7 This was also evident in the current study, where the 9-level modified version performed slightly better than the original one.…”

“…Regarding the GCS, its Greek version, 18 that has been in use for decades in Greek hospitals, was chosen for the purposes of the study. Therefore, an anew translation was not deemed necessary 19 …”

An efficient edge/cloud medical system for rapid detection of level of consciousness in emergency medicine based on explainable machine learning models

“…These features used to specify the percentage of carbon and oxygen in the blood, indicate the level of blood PH and patient's acid-base balance [98]. All of these are critical situations, affect patient response and may lead to sudden death [99,100]. Appendix A shows the feature names, Id, normal range and unit of measurement (UoM).…”