Table S1: Administration and scoring guidelines of the Simplified Evaluation of CONsciousness Disorders (SECONDs) and comparison with

the corresponding Coma Recovery Scale-Revised (CRS-R) item.

Item Administration guidelines Scoring guidelines Main criteria Criteria of CRS-R
corresponding item
Observe the patient for one minute and report spontaneous behaviors. If no See levels 1 and 5 below for instructions on N/A N/A
sustained eye opening is observed, administer auditory, tactile or noxious how to report those observations.
stimulation to arouse the patient. During the assessment, promote eye opening
Observation

before testing each item. If this is not possible, assess visual items and the capacity
to look up (on command) by manually opening the patient’s eyes.
During the whole assessment, observe the patient and report the presence of eye
opening, either spontaneously or to stimulation (report the number and type of
stimulation used when appropriate), as well as the presence of oriented non-
reflexive behaviors towards himself/herself or his/her environment (e.g.,
scratching nose, grabbing bedsheets, smiling in an appropriate context).
Ask the patient to produce a movement (e.g., move a limb or head, blink twice, Score “6” (response to command) if the patient Minimum 2/3 “Three clearly discernible
Response to command – Level 6

look at specific objects, look up, open/close your mouth, say a word, make a accurately responds to 2/3 trials for one succeeded for responses occur over the 4 trials
sound) that was not observed repeatedly during the observation period. Ensure the command. To be scored, the response must be one given on any one of the object or non-
commands circumvent physical limitations that might prevent the emergence of unequivocal, not spontaneously redundant and command object related commands.”
responses. must appear within the 10 seconds following
Administer three different commands and repeat each of them three times, leaving the command. All unclear or ambiguous
a 10-second interval after the end of the instruction. A command may be repeated responses as well as reflexive movements due
once within the 10-second trial in order to increase the patient’s motivation. to spasms or grasping reflexes should not be
If the first two commands are successfully performed (3/3 accurate responses), the scored. Report the commands used on the
third command does not need to be administered. In case of known or suspected scoring sheet as well as the number of
deafness, administer written commands. If the patient does not react to oral successful trials.
commands, at least one fourth additional written command should be
administered.
 The communication will be assessed only if the patient can express a “yes” and a Report the number of correct/incorrect Score “7”: 3 to Intentional communication
Communication (conditional) – Level 7 & 8
“no” (either verbally, or through gestures or writing, spontaneously or not) or if at responses. 5 answers, if “a clearly discernible
least two distinct responses to command are successfully performed (i.e., 2/3). In even if communicative response occurs
this last case, the communication code will be based on the responses previously Score “7” (intentional communication) if the inaccurate within 10 seconds on at least 2 of
identified. Make sure the code is clearly explained to the patient before starting patient responds to at least 3 out of the 5 the 6 visual or auditory
(e.g., thumbs-up for a “yes” and thumbs-down for a “no”). The examiner can questions, regardless of accuracy. situational orientation questions
restate the code used before each question. It is necessary to use two distinct (irrespective of accuracy)”.
Score “8”: 5
responses; the absence of movement or response cannot be used for a “yes” or a Score “8” (functional communication) if the accurate
“no”. patient correctly responds to the 5 questions Functional communication
The examiner will administer the following five binary autobiographical questions: (autobiographical or situational). if “clearly discernible and
(1) Is your name [incorrect name]? (2) Are you born in [correct birth year]? (3) Is accurate responses occur on all 6
your name [correct name]? (4) Are you born in [incorrect birth date]? (5) Do you of the questions.”
A score of “8” (functional communication)
have children?
should be obtained on 2 consecutive
If the patient seems to have difficulties with those questions (according to the
assessments to diagnose a patient as emerging
clinician), ask the following situational questions: (1) Are we at [(correct place),
from the minimally conscious state.
hospital, home or else]? (2) Am I wearing a hat (not wearing one)? (3) Are we at
the swimming pool? (4) Am I touching your face? (Touch) (5) Am I touching your
face? (Do not touch).
The patient’s gaze spontaneously follows the examiner moving around the room Score “4” if : Minimum 2 “Eyes must follow the mirror
with an uninterrupted and smooth eye movement in both left and right directions. - the patient’s gaze spontaneously and clearly pursuits without loss of fixation on 2
Visual pursuit –

If such a spontaneous visual pursuit cannot be observed, use a mirror and hold it in follows the examiner, who is silently moving (> 2 sec) occasions in any direction.”
Level 4

front of the patient, about 30 cm from his/her face. Move the mirror slowly (ensure around the bed, during at least two seconds on
the patient is always able to see his/her reflection) from left to the right (or right to two occasions.
left, according to the initial position of the patient’s eyes), from right to the left, - a smooth pursuit is observed in two directions
and then from top to bottom and from bottom to top. Each movement of the mirror during at least two seconds. Report the number
should last at least 4 seconds. of successful trials on each axis.
Minimum 2 “Eyes change from initial
Visual fixation – Level 3

The patient’s gaze spontaneously turns towards the examiner, performing a Score “3” if: fixations fixation point and fixate on the
saccadic eye movement, when the examiner enters into the patient’s visual field. If - the patient’s eyes spontaneously change their (> 2 sec) new target location for more than
such a spontaneous fixation cannot be observed, use a mirror and present it in all point of fixation towards the examiner for at 2 seconds. At least 2 episodes of
four quadrants of the patient’s visual field, but not in the axis of his/her gaze. The least two seconds and on two occasions. The fixation are required.”
mirror should be held about 30 cm from the patient’s face (ensure it is directed examiner should not initially stand in the axis
towards him/her). A clear change of gaze orientation towards the mirror should be of the patient’s gaze.
identified, followed by a fixation of at least two seconds. Report the quadrants in - a fixation is observed on two trials.
which the patient showed the fixations. - report the quadrants in which the patient
showed the fixations.
 This item should only be tested if the patient did not obtain a score above “5”. Put Score “2” (localization to pain) if, during at
a pen or pencil on the patient’s finger nail bed, wait for five seconds, then warn the least one of the two trials, the non-stimulated
Localization to pain –
patient that he/she will feel pain, and that this can be avoided if he/she withdraws hand of the patient touches the stimulated hand.
the hand. If the patient does not remove the hand within the next five seconds, Score “6” (response to command) if the patient
apply pressure on the nail bed using the pen or pencil for five seconds. One trial clearly removes his/her hand after the
Level 2
should be administered on each hand. instructions (and not during the five seconds
preceding it) but before the stimulus on both
trials.
See “Observation”. At the end of the assessment, score “0” (no
arousal) if, during the entire evaluation, the
patient never opened the eyes, even after
stimulation (including nociceptive stimulation).
Score “1” (arousal) if the patient opened the
Arousal – Level 1
eyes at least once during the assessment.
Specify if the eye opening happened
spontaneously or following a noxious, tactile or
auditory stimulation, as well as the number of
stimulations for each type that were
administered.
Report the percentage of eye opening time
throughout the entire examination: 0-25%; 25-
50%; 50-75%; 75-100%.
See “Observation” Score “5” if the patient presents at least one
Those may include (but are not limited to): scratching himself/herself, grabbing clearly observed oriented behavior. Document
behaviors –
Oriented
the bedsheets, holding the bed, pulling on the clothes/tracheostomy or gastrostomy the type and the number of occurrences for each
Level 5
tube/catheter, placing the hand on his/her mouth before coughing/yawning, observed behavior.
smiling/laughing/crying in an appropriate context, responding verbally or through
gestures when someone talks to him/her (independently of accuracy) or any other
automatic non-reflexive behaviors.
N/A, not applicable
This table was translated from French.
Minimum 1 “The non-stimulated limb must
localization locate and make contact with the
stimulated body part at the point
of stimulation on at least 2 of the
four trials.”
Note that, in the CRS-R, this item
rather requires to squeeze the
patient’s finger or toe between
the examiner’s thumb and index
finger, for a minimum of 5
seconds.
Eye-opening at Attention if “there are no more
least once than 3 occasions across the
length of the evaluation in which
the patient fails to respond to a
verbal prompt”.
Eye-opening without stimulation
if “eyes remain open across the
length of the examination without
the need for tactile, pressure or
noxious stimulation”.
Eye-opening with stimulation if
“tactile, pressure or noxious
stimulation must be applied at
least once during the examination
in order for the patient to sustain
eye opening”.
Minimum 1 At least 2 episodes of automatic
observation of motor behavior are observed
any oriented within the session and each
behavior episode can be clearly
differentiated from a reflexive
response.
Table S2. Individual clinical and demographic characteristics of individuals included in the study.
Patients Sex Etiology Age Time since SECONDs SECONDs best CRS-R
insult same day score score total score
(in months) (diagnosis) (diagnosis) (diagnosis)
P1 F Anoxic 59 1.84 1 1 7
(UWS) (UWS) (MCS-)
P2 F TBI 21 5.52 5 6 14
(MCS-) (MCS+) (MCS+)
P3 F Anoxic 70 1.38 4 4 5
(MCS-) (MCS-) (UWS)
P4 M TBI 24 5.29 1 1 6
(UWS) (UWS) (UWS)
P5 F Anoxic 58 9.21 8 8 20
(EMCS) (EMCS) (EMCS)
P6 M TBI 22 33.37 1 1 8
(UWS) (UWS) (MCS-)
P7 M TBI 60 11.28 8 8 23
(EMCS) (EMCS) (EMCS)
P8 M Other NTBI 64 13.12 4 4 9
(MCS-) (MCS-) (MCS-)
P9 M TBI 31 11.74 1 1 4
(UWS) (UWS) (UWS)
P10 M Anoxic 62 10.36 1 1 6
(UWS) (UWS) (UWS)
P11 F Other NTBI 49 68.58 8 8 21
(EMCS) (EMCS) (EMCS)
P12 F Anoxic 46 5.52 1 1 5
(UWS) (UWS) (UWS)
P13 F Anoxic 56 3.45 1 1 4
(UWS) (UWS) (UWS)
P14 M Other NTBI 31 4.14 5 5 9
(MCS-) (MCS-) (MCS-)
P15 M TBI 29 1.61 7 7 15
(MCS+) (MCS+) (MCS+)
P16 M TBI 18 5.52 8 8 20
(EMCS) (EMCS) (EMCS)
P17 M Anoxic 63 8.52 1 1 5
(UWS) (UWS) (UWS)
P18 M Anoxic 44 2.53 7 8 21
(MCS+) (EMCS) (EMCS)
P19 F TBI 68 3.68 5 5 12
(MCS-) (MCS-) (MCS-)
P20 M Anoxic 45 140.61 8 8 21
(EMCS) (EMCS) (EMCS)
P21 M TBI 37 95.97 6 6 13
(MCS+) (MCS+) (MCS-)
P22 M TBI 28 22.55 8 8 18
(EMCS) (EMCS) (EMCS)
P23 F TBI 74 148.90 8 8 22
(EMCS) (EMCS) (EMCS)
P24 F TBI 60 31.90 7 8 18
(MCS+) (EMCS) (EMCS)
P25 M TBI 56 196.99 6 6 12
(MCS+) (MCS+) (MCS+)
P26 F Other NTBI 45 43.96 4 4 10
(MCS-) (MCS-) (MCS+)
P27 F Other NTBI 50 2.99 3 4 6
(MCS-) (MCS-) (MCS-)
P28 M TBI 40 25.09 6 6 9
(MCS+) (MCS+) (MCS-)
P29 M TBI 20 5.75 7 7 15
(MCS+) (MCS+) (MCS+)
P30 M Other NTBI 62 2.53 1 1 5
(UWS) (UWS) (UWS)
P31 F Other NTBI 47 2.07 1 1 8
(UWS) (UWS) (MCS-)
P32 F Anoxic 31 5.06 6 6 8
(MCS+) (MCS+) (MCS+)
P33 M TBI 58 5.52 8 8 17
(EMCS) (EMCS) (MCS+)
P34 F Other NTBI 58 7.36 7 7 17
(MCS+) (MCS+) (MCS+)
P35 M TBI 48 7.59 8 8 23
(EMCS) (EMCS) (EMCS)
P36 F Other NTBI 85 2.76 5 5 14
(MCS-) (MCS-) (MCS-)
P37 F Other NTBI 47 9.67 8 8 16
(EMCS) (EMCS) (EMCS)
P38 M TBI 30 79.18 7 8 22
(MCS+) (EMCS) (EMCS)
P39 M TBI 34 5.29 4 4 8
(MCS-) (MCS-) (MCS-)
P40 F Other NTBI 39 41.66 4 5 7
(MCS-) (MCS-) (MCS-)
P41 M TBI 23 3.68 7 7 17
(MCS+) (MCS+) (MCS+)
P42 F TBI 26 25.09 1 1 5
(UWS) (UWS) (UWS)
P43 F TBI 64 0.92 1 1 6
(UWS) (UWS) (UWS)
P44 M Other NTBI 54 2.07 7 7 13
(MCS+) (MCS+) (MCS+)
P45 F Other NTBI 54 10.59 8 8 18
(EMCS) (EMCS) (EMCS)
P46 M Other NTBI 57 1.61 8 8 23
(EMCS) (EMCS) (EMCS)
P47 F Other NTBI 53 3.91 4 4 6
(MCS-) (MCS-) (MCS-)
P48 M Anoxic 49 5.75 8 8 23
(EMCS) (EMCS) (EMCS)
P49 M Other NTBI 56 3.22 8 8 18
(EMCS) (EMCS) (EMCS)
P50 M Other NTBI 46 9.67 8 8 14
(EMCS) (EMCS) (MCS+)
P51 F Other NTBI 65 1.84 1 4 4
(UWS) (MCS-) (UWS)
P52 M Anoxic 60 4.83 1 1 5
(UWS) (UWS) (UWS)
P53 M TBI 24 9.90 8 8 23
(EMCS) (EMCS) (EMCS)
P54 M Anoxic 72 1.84 4 7 16
(MCS-) (MCS+) (MCS+)
P55 M Anoxic 53 0.92 6 6 14
(MCS+) (MCS+) (MCS-)
 P56 M Other NTBI 76 0.92 7 7 19
(MCS+) (MCS+) (MCS+)
P57 M TBI 50 0.92 4 6 12
(MCS-) (MCS+) (MCS+)
- F: 23 (40%) -Anoxic: 14 (25%) Mean (SD) Mean (SD) - - -
-TBI: 24 (42%) 48.3 (16.2) 20.7 (39.1)
-Other NTBI: 19 Median (IQR) Median (IQR)
(33%) 50 (34-60) 5.5 (2.8-11.7)
M, male; F, female; TBI, traumatic brain injury; NTBI, non-traumatic brain injury; UWS, unresponsive wakefulness syndrome; MCS-, minimally conscious
state minus; MCS+, minimally conscious state plus; EMCS, emergence from the minimally conscious state; SD, standard deviation; IQR, interquartile range.