The Journal of TRAUMA威 Injury, Infection, and Critical Care

Improving the Glasgow Coma Scale Score: Motor Score

Alone Is a Better Predictor
C. Healey, MD, Turner M. Osler, MD, Frederick B. Rogers, MD, Mark A. Healey, MD, Laurent G. Glance, MD,
Patrick D. Kilgo, MS, Steven R. Shackford, MD, and J. Wayne Meredith, MD

Background: The Glasgow Coma
Scale (GCS) has served as an assessment
tool in head trauma and as a measure of
physiologic derangement in outcome mod-
els (e.g., TRISS and Acute Physiology and
Chronic Health Evaluation), but it has not
been rigorously examined as a predictor
of outcome.
Methods: Using a large trauma data
set (National Trauma Data Bank, N ⴝ
204,181), we compared the predictive
power (pseudo R2, receiver operating
characteristic [ROC]) and calibration of
the GCS to its components.
Results: The GCS is actually a col-
lection of 120 different combinations of its
3 predictors grouped into 12 different
scores by simple addition (motor [m] ⴙ
verbal [v] ⴙ eye [e] ⴝ GCS score). Prob-
lematically, different combinations sum-
ming to a single GCS score may actually
have very different mortalities. For exam-
ple, the GCS score of 4 can represent any
of three mve combinations: 2/1/1 (survival
ⴝ 0.52), 1/2/1 (survival ⴝ 0.73), or 1/1/2
(survival ⴝ 0.81). In addition, the rela-
tionship between GCS score and survival
is not linear, and furthermore, a logistic
model based on GCS score is poorly cali-
brated even after fractional polynomial
transformation. The m component of the
GCS, by contrast, is not only linearly re-
lated to survival, but preserves almost all
the predictive power of the GCS (ROCGCS
ⴝ 0.89, ROCm ⴝ 0.87; pseudo R2GCS ⴝ
0.42, pseudo R2m ⴝ 0.40) and has a better
calibrated logistic model.
Conclusion: Because the motor com-
ponent of the GCS contains virtually all
the information of the GCS itself, can be
measured in intubated patients, and is
much better behaved statistically than the
GCS, we believe that the motor compo-
nent of the GCS should replace the GCS
in outcome prediction models. Because the
m component is nonlinear in the log odds
of survival, however, it should be mathe-
matically transformed before its inclusion
in broader outcome prediction models.
Key Words: Glasgow Coma Scale,
Predictive power, Outcome.
J Trauma. 2003;54:671–680.

T
he Glasgow Coma Scale (GCS)1 was introduced a quar-
ter of a century ago and is now a part of the bedrock of
outcome prediction after head injury. Created to be re-
liably used even by workers without specialized training, the
GCS seems straightforward: it is simply the sum of three
coded values that describe a patient’s motor (1– 6) verbal
(1–5), and eye (1– 4) level of response to speech or pain.
Since its creation, the GCS has been widely used. Not only is
it used to describe individual trauma patients in the ambu-
lance, the emergency room, and the intensive care unit, but it
is also used as a component of several other outcome predic-
tion scores: the Revised Trauma Score;2 Acute Physiology
and Chronic Health Evaluation;3 TRISS;4 Circulation, Res-
piration, Abdomen, Motor, Speech Scale; and A Severity
Characterization of Trauma5 all use the GCS as a predictor.
Submitted for publication October 9, 2002.
Accepted for publication January 6, 2003.
Copyright © 2003 by Lippincott Williams & Wilkins, Inc.
From the Department of Surgery, University of Vermont, College of
Medicine (C.H., T.M.O., F.B.R., M.A.H., S.R.S.), Burlington, Vermont,
Department of Anesthesia, University of Rochester (L.G.G., P.D.K.), Roch-
ester, New York, and Department of Surgery, Wake Forest University
School of Medicine (J.W.M.), Winston-Salem, North Carolina.
Presented at the 61st Annual Meeting of the American Association for
the Surgery of Trauma, September 26 –28, 2002, Orlando, Florida.
Address for reprints: Turner M. Osler, MD, FACS, Department of
Surgery, University of Vermont, 111 Colchester Avenue, FL 466, Burling-
ton, VT 05401; email: turner.osler@vtmednet.org.
DOI: 10.1097/01.TA.0000058130.30490.5D
Given the fundamental importance of the GCS, it may
seem remarkable that this score has never been subjected to
careful statistical evaluation. However, the GCS was ac-
cepted as a useful description of consciousness and powerful
predictor of outcome long before large databases required for
rigorous statistical analysis were available. Although many
authors (its creators among them) have noted shortcomings in
the GCS, including the inability to calculate the GCS score
for many patients6,7 and poor statistical performance,8 we
believe a reappraisal is in order. The data available in the
National Trauma Data Bank (NTDB) provide a powerful tool
for this analysis. We hypothesized that most of the power of
the GCS resides in the motor component and that the addition
of the verbal and eye components add little to the predictive
power of the GCS. Moreover, we thought it likely that the
addition of the verbal and eye subscores would undermine
useful mathematical characteristics of the motor-only model
of consciousness.
PATIENTS AND METHODS
The American College of Surgeons established the
NTDB as a national repository of trauma data. It contains
information supplied by 89 hospitals from around the country
representing Level I, II, and III trauma centers. Although the
NTDB includes a wide variety of information for each case,
for this study only GCS subscores (motor [m], values coded
1– 6 or blank; verbal [v], values coded 1–5 or blank; and eye
[e], values coded 1– 4 or blank) and outcome (survival to

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 The Journal of TRAUMA威 Injury, Infection, and Critical Care

hospital discharge or death) were available. Cases were col-

lected between 1994 and 2001 and represented all age groups.
We examined the individual predictor elements of the
GCS for availability in the NTDB, linearity with respect to
survival, and linearity in the log odds of survival (fractional
polynomial analysis,9 see Appendix). Survival models were
then constructed using the subscores of the GCS (m, v, and e)
individually and as simple sums (m ⫹ v, m ⫹ v ⫹ e ⫽ GCS
score). Although the focus of this analysis was on the dis-
crimination rather than the calibration of these models, math-
ematical transformations of predictors in these models were
also examined using the technique of fractional polynomial
analysis10 to optimize calibration (see Appendix). Survival
models were evaluated for discrimination (receiver operating
characteristic [ROC] curve area), overall percentage of vari-
ability explained by the model (pseudo R2),11 misclassifica-
tion rate, and calibration, which was assessed with the Pear-
son ␹2 statistic. (The Hosmer-Lemeshow statistic was not
examined because several models had only a few different
covariate patterns, a circumstance that so reduced the power
of the Hosmer-Lemeshow statistic as to make it
meaningless.12) In addition, Akaike’s information criteria13
were computed as a measure of overall information for each
model. Ninety-five percent confidence intervals for ROC
values were calculated using a resampling algorithm and
statistical significance of differences between ROC statistics
were calculated using the nonparametric method of Hanley
and McNeil.14 All analysis was performed using Intercooled
STATA version 7.0 (College Station, TX). Model evaluation
was performed using SPost commands.15 Fig. 1. The frequency of various GCS scores in the data set. Note
that almost 80% of patients in the NTDB had a GCS score of 15.
RESULTS GCS scores of 14 and 3 were also common (approximately 6%
The NTDB data set used in this analysis included a total each), but other scores occurred in less than 1% of cases.
of 204,181 cases. However, 177 eye subscores, 1,583 verbal
subscores, and 673 motor subscores were unrecorded. As a following motor-verbal-eye (mve) groupings: 2/1/1, 1/2/1, or
result, a total of 1,926 GCS scores were unavailable. Overall 1/1/2. A GCS score of 9 can be attained by any of 18 different
mortality for the data set was 6%, but for the 1,926 patients mve combinations. Overall, 120 different mve combinations
for whom the GCS score was unavailable the overall mortal- are possible, but this multitude of combinations collapse into
ity was higher: 9.8% overall mortality for any missing sub- just 13 different GCS scores (3–15 inclusive) by the simple
score, 6.84% mortality for missing motor score, 12.99% mor- convention of summing the subscores. Unfortunately, we
tality for missing eye score, and 9.92% mortality for missing found that different mve combinations resulting in a single
verbal score). Of the 1,926 patients with no available GCS GCS score may have very different mortalities. Thus, al-
score, 675 patients also had no motor score (mortality, though the mve combination 1/2/1 (GCS score of 4) has a
6.84%) and 1,253 patients did have a motor score available mortality of 28%, the mve combination 2/1/1 (GCS score of
(mortality, 11.41%). The remainder of this analysis is based 4) has a mortality almost twice as high (52%) (p ⫽ 0.000,
on the 202,255 patients for whom all GCS subscores were Fisher’s exact test). Such discrepancies are not rare in the
available. GCS. In fact, every GCS score in this data set has such
Eighty percent of GCS scores were 15. GCS scores of 14 discrepancies that are statistically significant except 3 and 15
and 3 were also frequent, with approximately 6% of obser- (by definition) and 6, 12, and 13 (Fig. 2).
vations in each group. GCS scores from 4 through 13 (inclu- Survival proved to be a very nonlinear function of the
sive) were much less common, with less than 1% of obser- GCS. Moreover, survival was nonlinear for each of the GCS
vations in most groups (Fig. 1). subscores except the motor subscore, which in contrast was
In reality, every GCS score except 3 and 15 is a collec- strikingly linear (Fig. 3). Neither GCS score nor its motor
tion of several different possible groupings of subscores. component score were linear in the log odds of survival, but
Thus, a GCS score of 4 may be achieved by any of the the motor score is far less irregular (Fig. 4).

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 Improving the Glasgow Coma Scale Score

Fig. 2. The 120 possible combinations of GCS subscores with their survival rates (and 95% confidence interval) grouped by GCS score.
Although the GCS is commonly thought of as 13 possible scores ranging from 3 to 15, it is actually 120 different possible combinations of
its component subscores that are grouped into 13 individual “scores” by the simple expedient of addition. Unfortunately, different
combinations of subscores that sum to the same GCS score often have very different survival rates.

The ability of the GCS to predict survival was evaluated
and compared with models based on its individual component
subscores (m, v, and e) and the sum of its motor and verbal
scores (m ⫹ v) to determine where the predictive power of
GCS arises. Two further survival prediction models, one
based on GCS (“fracpoly GCS model”) and one based on the
motor component of GCS alone (“fracpoly m model”) were
also created using the technique of fractional polynomial
analysis to improve the fit of these single predictors. Finally,
a model containing all GCS subscores and their interaction
terms appropriately transformed using the technique of mul-
tiple fractional polynomials combined into a single predictor
(“multiple fracpoly GCS model”) was created and evaluated.
This final model represents the state-of-the-art approach to
the three predictors available in the GCS. The performance of
these eight models is presented in Table 1. We note first that

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Fig. 3. Survival as a function of the eye, verbal, and motor scores, and their sum, the GCS score. Note that both the eye and verbal scores
are distinctly nonlinear and that this is reflected in the GCS score. The motor score, by contrast, is very linear.

removing the eye component from the GCS results in a model
(m ⫹ v) indistinguishable from the GCS (m ⫹ v ⫹ e): not
only are the ROC and pseudo R2 values the same for these
two models, but the smaller, more parsimonious m ⫹ v model
is actually slightly better calibrated. The further elimination
of the verbal subscore from the GCS leaves the “motor-only
score” model. This further simplification results in a small
but statistically significant decrease in performance: ROC
falls (ROCGCS ⫽ 0.891 vs. ROCm ⫽ 0.873, p ⫽ 0.000), as
does pseudo R2 (pseudo R2GCS ⫽ 0.416 vs. pseudo R2m ⫽
0.403), and misclassifications increase (GCS ⫽ 4.9% vs. m ⫽
5.1).
Elimination of all patients with a GCS score of 15 from
the data set resulted in worse performance of all models, but
the relative rankings of models were largely unchanged.
However, the difference in ROC values for the m and GCS
scores was reduced by 50%. This suggests that the improve-
ment in prediction resulting from literally adding v and e
scores to the m score is largely attributable to the superior
discrimination of the GCS in patients with a normal level of
consciousness (data not shown).
All models are poorly calibrated as assessed by the
Pearson ␹2 statistic, but calibration is improved by mathe-
matically transforming predictors using the technique of frac-
tional polynomials before creating a logistic model. For ex-
ample, the logistic model based on m alone can be
transformed by including the inverse square root of m and the
third power of m in the logistic model with considerable

Fig. 4. Neither the GCS score nor its motor component are linear in the log odds of survival. However, the motor score is far less irregular.

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 Improving the Glasgow Coma Scale Score

Table 1 Comparison of Prediction Models

Covariate Misclassification Psuedo Pearson’s ␹2
Model Transformations ROC (95% CI) AIC
Patterns (95% CI) (%) R2 (df)

m 6 — 0.873 (0.870–0.875) 5.1 0.403 0.270 604.7 (4)

v 5 — 0.0881 (0.875–0.883) 6.0 0.382 0.279 224.2 (3)
e 4 — 0.858 (0.854–0.862) 6.0 0.376 0.282 138.8 (2)
m⫹v 10 — 0.890 (0.886–0.893) 5.0 0.418 0.263 324.3 (8)
GCS score (m ⫹ v ⫹ e) 13 — 0.891 (0.888–0.894) 4.9 0.416 0.263 656.6 (11)
Fractional polynomial m 6 m–1/2, m3 0.873 (0.870–0.875) 5.1 0.408 0.269 30.8 (3)
Fractional polynomial GCS 13 GCS–2, GCS3 0.891 (0.888–0.894) 4.9 0.420 0.262 313.6 (10)
f (m, v, e, me, mv, ev, mev) 118 m–3 v–2 me–1/2 mv3, ev–2, mev2 0.891 (0.888–0.894) 4.9 0.424 0.260 151.3
ROC, receiver operating characteristic; CI, confidence interval; AIC, Akaike’s information criteria; df, degrees of freedom.

improvement in calibration. Although this transformed model
is still not “well calibrated” (i.e., Pearson ␹2 value of 30 on 3
degrees of freedom results in a value of p ⬍ 0.001), to casual
examination calibration is quite good (Fig. 5). Transforma-
tion of the GCS score using the inverse square of the GCS
score and the third power of the GCS score is much less
successful because of the nonmonotonic nature of the GCS
score (Fig. 6).
DISCUSSION
The GCS was developed in 1974 by Teasdale and Jennett
as a practical way to measure the “depth and duration of
impaired consciousness” in a variety of conditions including
head trauma. Simplicity was the overriding design concern,
with the goal of interrater reliability even by staff without
special training. As originally proposed, the GCS score was
reported as three independent subscores (motor, verbal, and
eye). The further simplification of recording only the sum of
the three components as a single score was adopted by Teas-
dale and Jennett in 1977.
Interestingly, the creators of the GCS foresaw possible
shortcomings in their score. In their original article, they
noted that some components of the score might be impossible
to assess. Of perhaps greater significance, in their 1977 dis-
cussion they observed that “[the] validity of the assumption
that each of the three parts of the scale should count equally
and that each step should differ equally from that next to it
has still to be tested.”
Teasdale and Jennett were not able to evaluate these
concerns, perhaps because they did not have large patient
databases available to them. Their concerns were well
founded, however. Numerous authors have since observed
that trauma patients who are inebriated, intubated, or phar-
macologically paralyzed cannot have their GCS score as-
sessed. This is a particularly troublesome problem because it
is precisely these patients who are at the highest risk of dying.
This problem is compounded by the wide variety of ways it
has been “solved” at different trauma centers, such as scoring
components as the minimum possible value, the maximum
possible value, as a “T,” or simply as “unknown.”16,17 At-
tempts at a unified solution, such as imputation of missing
values using a linear regression model,18,19 have not been
adopted, perhaps because the formula is complicated and may
not apply equally well to all case mixes. Other authors have

Fig. 5. The motor-only logistic model (dashed line) is poorly calibrated, but mathematical transformation of the motor score greatly improves
calibration (dotted line). The solid line represents perfect calibration (predicted mortality ⫽ actual mortality).

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 The Journal of TRAUMA威 Injury, Infection, and Critical Care
Fig. 6. The GCS logistic model (dashed line) is poorly calibrated, but mathematical transformation of the GCS score somewhat improves
calibration (dotted line). The solid line represents perfect calibration (predicted mortality ⫽ actual mortality).
advocated for the simple replacement of the GCS score with
the motor score alone20 or in place of the GCS score in the
Revised Trauma Score.21 These last studies are persuasive
but were based on small data sets. Still another approach is
the use of the Reaction Level Scale,22 which has eight values
and resembles an enhanced motor subscore.
We believe that the eye subscore should certainly be
removed from the GCS because it adds nothing to the pre-
dictive power of the model and is occasionally impossible to
obtain. The choice to remove the verbal subscore is more
difficult, because the presence of the verbal subscore does
improve the model of impaired consciousness at a statistically
significant level. Nevertheless, we believe that the verbal
subscore should also be removed because its contribution is
not great and it is occasionally impossible to assess (i.e.,
intubated patients or inebriated patients). Thus, we advocate
the motor subscore as the best choice for a level-of-con-
sciousness indicator. Although this model preserves most of
the power of the GCS, it avoids the problems inherent in
collecting the verbal and eye components of the GCS. More-
over, its linearity with respect to survival is far more intuitive
and easily remembered than the complex survival graph of
the GCS.
There are two circumstances in which the motor-only
model is unreliable: in patients with pharmacologic (thera-
peutic) paralysis and in patients with traumatic paralysis (i.e.,
high spinal cord injuries). In these cases, the motor score is
simply not a measure of consciousness and cannot be used as
one. In the case of pharmacologic paralysis, it is a simple
matter to allow the drug to wear off before assessing the
motor subscore. The case of quadriplegia is more difficult to
deal with, but it is possible that a standardized group of facial
responses to voice and noxious stimuli can be developed with
only slight loss of accuracy overall.
676
Although the motor subscore is a powerful predictor of
mortality, we do not expect it to be used in isolation, because
other predictors (e.g., injury severity, age, comorbidities) are
also known to influence outcome. Rather, the motor subscore
will be used as a component of a larger, more comprehensive
survival model. When the motor subscore is incorporated into
such a model, however, it will be important that it first be
mathematically transformed to be linear in the log odds of
survival, because this is a condition of the logistic model.
This study has limitations. Most importantly, it is based
on a cohort of trauma patients in whom all GCS subscores
were recorded in the NTDB, and therefore its applicability to
patients in whom not all subscores were available is not
certain. Moreover, in patients in whom all subscores were
assigned the procedures for assigning scores is likely to have
been subject to local conventions that were almost certainly
not uniform. These two problems may have biased the results
of this study in unpredictable ways. Nevertheless, this study
represents by far the largest and most comprehensive exam-
ination of the GCS available to date.
CONCLUSION
In summary, the GCS is composed of three subscores
that contain redundant information. The simple addition of
these subscores to create the GCS, although convenient, re-
sults in a nonlinear relationship between the GCS score and
mortality. We found that the motor component of the GCS
score is a powerful predictor of outcome and contains most of
the predictive power of the score. The addition of the verbal
subscore adds slightly to the predictive power, but the further
addition of the eye subscore (resulting in the familiar GCS
score) adds nothing to predictive power. We believe that a
motor subscore-only model of level of consciousness is the
most practical because the verbal score may be impossible to
April 2003

obtain in seriously injured patients. Adding to the appeal of
the motor-only model is its near linearity with respect to
mortality. Quadriplegia is a potentially problematic injury
because it naturally confounds the motor-only score. Six
levels of the motor score based on physical examination of
the face will need to be defined to make the motor-only score
universally calculable. Finally, the motor-only score will re-
quire mathematical transformation to ensure linearity in the
log odds of survival before incorporation into more compre-
hensive logistic models of survival.
APPENDIX
Discrimination and Calibration of Survival Models
Survival predictions are based on mathematical models
that take the values of one or more predictors and allow the
calculation of the outcome of interest (typically, death in
trauma outcome models). There are many possible prediction
models, and so the business of selecting the “best” model is
of obvious interest. Unfortunately, measuring how well a
predictive model performs is not straightforward. Two broad
measures of models are discrimination and goodness-of-fit.
Discrimination is the degree to which a model separates
survivors from nonsurvivors. This is usually quantified as the
area under the ROC curve. The ROC curve varies from 0.5
(separation of survivors from nonsurvivors is no better than
chance alone) to 1.0 (perfect separation of survivors from
nonsurvivors). Although the actual calculation of the ROC
curve is not straightforward, in principle it could be calcu-
lated by repeatedly randomly selecting a survivor and a non-
survivor and recording whether the model under consider-
ation correctly predicts the survivor. The percentage of
randomly selected pairs correctly predicted by the model is its
ROC curve statistic. Although the ROC curve is conceptually
simple, in practice its use requires some care. For example,
the actual value of the ROC curve for a model depends on the
distribution of cases in the data set. Thus, in order for two
different models to be compared with respect to ROC curve,
the identical data set must be evaluated by each model. As an
additional complexity, the results of such model comparisons
may actually change with different data sets, again depending
on case mix.
Goodness-of-fit tests attempt to capture how well a
model predicts outcome throughout the range of predictions.
That is, for a model to have acceptable goodness-of-fit, we
wish the differences between predicted and actual outcomes
to be small and, furthermore, that errors be unsystematically
distributed. Unfortunately, there are many goodness-of-fit
tests and no agreement on which is “best.” The oldest such
test is the Pearson ␹2. Because the Pearson ␹2 tests whether a
model’s calibration is indistinguishable from “perfectly cali-
brated,” the very large data sets used in trauma outcome
research almost always have sufficient power to reject the
“perfectly calibrated” hypothesis, and thus the judgment “not
perfectly calibrated” is not very informative. The Hosmer-
Lemeshow test is another goodness-of-fit test that has been
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Improving the Glasgow Coma Scale Score
used extensively in trauma research. Unfortunately, because
this test requires grouping the data into at least 6 (and pref-
erably 10) groups based on outcome score, for scores such as
the m, v, and e subscores of the GCS it is simply not
applicable. Moreover, when most patients’ predictors fall into
a single covariate pattern, it can be impossible to partition the
data to allow the calculation of the Hosmer-Lemeshow
statistic.
For the purposes of this article, we chose to examine
three measures of goodness-of-fit: overall misclassification
rate, McFadden’s R2, and Akaike’s information criterion. We
selected overall misclassification because it is unambiguous
in its interpretation and easily calculated: one simply finds a
cutpoint in the score that minimizes misclassifications and
reports this rate. We chose to report McFadden’s (pseudo) R2
because of its analogy to R2 in linear regression, where R2
represents the percentage of variability explained by a model.
Although this interpretation of the pseudo R2 is not strictly
correct for logistic models, because the pseudo R2 values
reported here are all calculated using the same data set, it is
appropriate to compare this statistic between models. Finally,
we chose to examine Akaike’s information criteria, which
examines the amount of information contained in a score
based on the likelihood of the data observed given the model
under consideration corrected for the number of predictors in
the model. Although the absolute level of Akaike’s informa-
tion criteria is uninformative, lower values imply more infor-
mation conveyed by a model.
We believe that the most informative and convenient
approach to goodness-of-fit is a simple graph of predicted
survival versus actual survival for each covariate pattern. Not
only does this single graph display the performance of a
model throughout its range, but it is also immediately inter-
pretable: the closer such a line lies to the diagonal, the more
reliable the prediction model. Another attractive feature of
this graphical approach to goodness-of-fit is that it is not
affected by case mix.
Fractional Polynomial Analysis
A fractional polynomial (FP) is a polynomial whose
powers are integers or fractions that may be positive, zero, or
negative. Introduced by Royston and Altman in 1994,23 FPs
are extremely useful in regression models because they offer
greater flexibility than ordinary polynomials. In multivariate
regression models, FPs allow us to preserve the continuous
nature of predictor variables even when such variables are
originally nonlinear and thus allow the creation of better
calibrated models. Alternatively, if a model based on FP
transformations fails to improve on untransformed predictors,
we can be assured that the regression is in fact linear in its
predictors.9
As implemented in STATA, a back-fitting algorithm is
used that finds a fractional polynomial transformation for
each predictor in turn, while holding the functional forms of
the other predictors temporarily fixed. The algorithm con-
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verges when the functional forms of the predictors do not
change.
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678
DISCUSSION
Dr. Randall M. Chesnut (Portland, Oregon): Having
spent a bit of my training time in Glasgow and gotten to know
fairly well Brian Jennett and Graham Teasdale, I could tell
you that even the authors are quite impressed by how far this
little scale got, which was essentially developed over a sum-
mer evening drinking a wee bit of Scotch.
This article is a statistical tour de force that represents the
first thorough analysis of the mathematical behavior and
predictive value of the Glasgow Coma Scale and its compo-
nent scores in a large database from the general trauma
population. On the basis of their excellent statistical method-
ology, the authors conclude that the vast majority of the
useful predictive value of the GCS lies in the motor compo-
nent; therefore, the verbal and eye subscales should be
discarded.
Although I find this article very well done, and I believe
that their results accurately reflect the data, I’m inclined to
exercise significant caution with respect to generalizing the
conclusions. I have three criticisms of this article, the first
two of which are fairly predictable.
This article relies critically on the validity of the data
analyzed. Unfortunately, as shown multiple times in the lit-
erature, the GCS score is notoriously difficult to collect
reliably. Optimally, it is collected by trained observers in the
absence of drugs after complete physiologic resuscitation.
Unfortunately, nowhere in this article is described the reli-
ability of the GCS values collected by many different people
at multiple centers. Would the authors please fill us in on
these details.
The second two criticisms revolve around the traumatic
brain injury population. Although this study addressed the
general trauma population, the GCS was developed for use in
patients with suspected neurologic deficits. For the brain
injury population, survival to discharge is a terrible index of
outcome, because it completely neglects the quality of life in
survivorship. I realize that survival to discharge was used
here as an endpoint of convenience, given the database avail-
able, but I do not believe that any analysis of brain injury–
related data can be deemed complete or valid if based solely
on mortality figures.
The third criticism is the most important. This study
addressed the general trauma population and not a brain
injury population. When present, brain injury is highly deter-
minant of outcome. In this article, however, 90% of patients
had a GCS score of 15, which is the same GCS score that
presumably most of the people in this audience have. Also,
the mortality for the 13,114 patients in this study that had a
GCS score of 3 was 58%, which is the more expected mor-
tality of 75% to 80% in traumatic brain injury studies. In
addition, we know nothing of the intracranial diagnoses of
these patients, their pupillary examination, or other relevant
indices of neurologic function. Therefore, there is no indica-
tion that this study reflects the brain injury population. Be-
April 2003

cause the major value of the GCS is in the area of traumatic
brain injury, any recommendations to change its collection or
interpretation must be based on investigations into the trau-
matic brain injury population, per se, using long-term func-
tional outcome.
This article makes a very strong statement that the motor
subscale of the GCS can and probably should replace the
whole GCS in modeling studies of short-term mortality in the
general trauma population. I do not, however, believe that it
has any implications regarding the clinical use of the GCS at
this time or in prognostic modeling specific to the traumatic
brain injury population. I hope that further efforts from this
excellent group will allow us to take these steps.
Dr. Pascal Udekwu (Raleigh, North Carolina): Having
had the opportunity to look at the North Carolina Trauma
Registry data set on head injury patients based on Interna-
tional Classification of Diseases, Ninth Revision codes, I
have to say that our conclusions really support those pre-
sented here today. I think that our results are also strength-
ened by the fact that a subset of patients had Functional
Independence Measure scores that provide some support in
terms of functional outcome as opposed to mortality alone.
So, I would like to say, wonderful article. Thank you very
much. I look forward to its publication.
Dr. Howard R. Champion (Annapolis, Maryland): I
would like to, first of all, state that I agree entirely with your
conclusions, as far as they go. I need to take issue with the
first reviewer in terms of the way in which it may in any way
reflect on Scotch whiskey. The GCS was devised in a pub,
and is thus more a reflection of Glasgow beer than the fine
Scotch whiskey that is also found in that country.
From a historical point of view, the Glasgow Coma Scale
was developed to measure coma in head-injured patients 24
hours or so after injury. When we applied it in prehospital
care in this country, to get around terms such as “lethargy”
and “stupor” as the descriptors for head injury, Graham
Teasdale was actually very upset with that concept.
He said, “It wasn’t designed for that” and “should not be
applied in that area.” The questions I have are two: first, when
you take the measure of coma down from the 15-integer
Glasgow Coma Scale to best motor response, although it
makes an awful lot of sense, you’re taking the measurement
of coma to five intervals. Most neurosurgeons would say that
is insufficient to characterize head injury in any way in
relationship to any outcome.
The other thing is that the Glasgow Coma Scale relation-
ship to mortality differs considerably between blunt and pen-
etrating injury to the head. How do you account for this?
How are you going to address these two issues if you’re
just going to distill it and simplify it? Your proposal has
certain advantages for certain users but big disadvantages for
others.
Dr. K. Dean Gubler (Portland, Oregon): I appreciate
this article, the presentation, and the amount of work to
contemplate. When you combine measures and then try to
Volume 54 • Number 4
Improving the Glasgow Coma Scale Score
simplify it into a single measure, you lose information. The
Glasgow Coma Scale score is a measure of brain injury. My
concern is that the way the Glasgow Coma Scale is scored
across this country, it’s more a global assessment of neuro-
logic injury.
Did you consider taking out patients with diagnoses of
spinal cord injury and seeing how the day-to-day measure-
ment of the Glasgow Coma Scale is affected? Could you then
get best motor score related to brain injury and get rid of the
noise from including spinal cord injuries? Are your findings
more a reflection of coding based on spinal cord injury and
not on head injury?
Dr. Turner M. Osler (closing): Dr. Chestnut, thank you
for those insightful thoughts. I, too, am troubled by the
National Trauma Data Bank because it’s too good to be true:
You send some email, and you get 200,000 cases to work on.
The problem with not having collected the data yourself or
participating in the data collection is that you can never know
what’s going on there.
I am extremely troubled by the fact that in the NTDB
only 2,000 cases lacked a component of the Glasgow Coma
Scale. That would be 1%. That’s inconceivable. So, we know
that this data set must have people filling in blanks, perhaps
according to local protocols that they just assign a 1 or they
just assign some of the highest possible number, the lowest
possible number. We don’t know what these conventions
were. They could, of course, bias the data. We have no way
of knowing in what direction they would have biased the
data. However, given the data set, it’s not a problem we can
solve except by having a better data set. So, this study
obviously needs to be repeated.
To comment on the traumatic brain injury population, it
is true that Teasdale and Jennett conceived the Glasgow
Coma Scale to deal with brain surgery and brain injury. They
weren’t really thinking about the trauma population. What
has been discovered, however, is that in severely traumatized
patients who are in a shock-like state, their Glasgow Coma
Scale score will fall off.
As a measure of overall illness, it turns out that the
Glasgow Coma Scale is quite powerful. Thus, it has been
incorporated into our trauma models. That’s not to say that
what we are actually measuring is brain injury. Many patients
with a depressed Glasgow Coma Scale score have no brain
injury at all; they are merely in shock. The GCS, however, is
a powerful predictor, and it may be that the GCS score is just
a surrogate for shock.
I agree that for the day-to-day work of a brain surgeon,
having all three components of the GSC may be helpful.
However, looking at a broader trauma population, which is
what our mandate was, I think that it’s clear that the motor
score contains virtually all of the power. I hope that covers
your questions.
Dr. Champion, Thank you. Those are both excellent
points. I think that what I’m doing is not for neurosurgeons.
679
 The Journal of TRAUMA威 Injury, Infection, and Critical Care
What I’m doing is for trauma demography and outcome
prediction. I think it’s perfectly appropriate for neurosur-
geons to continue to use whatever scale they want, and I think
they are aware that a GCS score of 7 equals a GCS score of
8 equals a GCS score of 9 equals a GCS score of 10 equals
a GCS score 11. They’re aware of that foible, and our math-
ematical models need to be aware of that foible as well.
I think the blunt-penetrating distinction is an important
one, but most of our trauma registries don’t contain very
much penetrating head trauma. Therefore, it doesn’t really
affect the conclusions of an article that’s looking at such a
large number of patients.
Thank you Dr. Gubler, those are good thoughts. We, too,
are concerned about the spinal cord injury problem, because
in the case of a quadriplegic, the motor score goes to 1, and
680
of course, this doesn’t reflect anything about the brain. We
propose that if we’re going to use the motor score alone, there
needs to be a special score for quadriplegics based on just
their facial response to noxious stimuli or voice that would
fill in the gap. However, quadriplegics don’t represent a large
category in anybody’s data set, so that hasn’t affected our
overall results.
I’d like to underscore, again, that the Glasgow Coma
Scale, although it was conceived to measure brain injury,
isn’t measuring brain injury—it’s measuring brain function,
and brain function can be affected by many things, including
shock. So, the reason the Glasgow Coma Scale works so well
as the predictor in general trauma populations is because it’s
measuring a lot of different things, not just brain injury.
Thank you very much.
April 2003