Correspondence (reply): In Reply

We like to thank our colleagues who have played a crucial role in shaping our understanding of PVS over the past decades for their important additions. Our focus was on the systematic meta-analysis of studies describing technical methods that help to differentiate between PVS and MCS (1). Unfortunately, we could not discuss all aspects and all important preparatory work related to this complex topic—not least because of the limited space available. We share the view that the German Coma Remission Scale (KRS) is an important instrument for evaluating the clinical course of patients with disturbances of consciousness. The use of an appropriate clinical examination method to differentiate between PVS and MCS was one key inclusion criterion for our analysis. The majority of the studies we identified were from non-German-speaking countries and used the Coma Recovery Scale-Revised (CRS-R) as an evidence-based, bed-side examination method with a good test quality profile and clearly operationalized differentiation between PVS and MCS (2). However, the use of CRS-R was by no means compulsory. It is crucial to use internationally established assessment tools to advance this area of research in Germany, too; in fact, this approach has already been adopted by German-speaking working groups (3). We have critically discussed (1) that the use of the CRS-R is associated with significant methodological risks and evaluated the quality of the studies especially based on the clinical examination method used (eTable in the article). To reduce the rate of clinical misdiagnosis, we firmly support the expert group’s call for improved advanced training and continuing education for physicians in the assessment of disturbances of consciousness. Major neurological textbooks should have a special chapter exclusively dedicated to this topic. It should be ensured that seeing and managing this type of patients in a clinical setting is an integral part of specialist training.