How often is the diagnosis of the permanent vegetative state incorrect? : A review of the evidence

Background. Some research suggests that 40% of people in the vegetative state are misdiagnosed. This review investigates the frequency, nature and causes of reported misdiagnosis of patients in the vegetative state, focusing on the nature of the error. Method. A systematic review of all relevant literature, using references from key papers identified. Data summarised in tables. Results. Five clinical studies of rate of misdiagnosis in practice were identified, encompassing 236 patients in the vegetative state of whom 80 (34%) were reclassified has having some awareness, often minimal. The studies often included patients in the recovery phase after acute injury, and were poorly reported. Five systematic reviews of signs and technologically-based neurophysiological tests were identified, and they showed that most studies were small, lacked accurate or important details, and were subject to bias. Studies were not replicated. Many signs and tests did not differ between people in the vegetative and minimally conscious state, and those that did were unable to diagnose an individual patient. The few single case reports suggest that failure to ensure an accurate diagnosis of the underlying neurological damage and dysfunction could, rarely, lead to significant misdiagnosis usually in patients who had brain-stem damage with little thalamic or cortical damage. Conclusions. Significant misdiagnosis of awareness, with an apparently ‘vegetative’ patient having good awareness, is rare. Careful neurological assessment of the cause and routine measurement of awareness using the Coma Recovery Scale- Revised should further reduce mistakes

Rehabilitation interventions for foot drop in neuromuscular disease

"Foot drop" or "Floppy foot drop" is the term commonly used to describe weakness or contracture of the muscles around the ankle joint. It may arise from many neuromuscular diseases

How many patients in a prolonged disorder of consciousness might need a best interests meeting about starting or continuing gastrostomy feeding?

Objective. To estimate the number of people in a prolonged disorder of consciousness (PDOC) who may need a formal best interests decision-making process to consider starting and/or continuing life-sustaining treatment each year in the population of a developed country. Method. Identification of studies on people with a prolonged disorder of consciousness giving information about incidence, and/or prevalence, and/or cause ,and/or location of long-term care. Sources included systematic reviews, a new search of Medline (April 2018), and a personal collection of papers. Validating information was sought from existing data on services. Results. There are few epidemiologically sound studies, most having bias and/or missing information. The best estimate of incidence of PDOC due to acute-onset disease is 2.6/100,000/year; the best estimate of prevalence is between 2.0 and 5.0/100,000. There is evidence that prevalence in the Netherlands is about 10% of that in other countries. The commonest documented causes are cerebral hypoxia, stroke, traumatic brain injury, and tumours. There is some evidence suggesting that dementia is a common cause, but PDOC due to progressive disorders has not been studied systematically. Most people receive long-term in nursing homes, but a significant proportion (10%-15%) may be cared for at home. Conclusion. Each year about 5/100,000 people will enter a prolonged state of unconsciousness from acute onset and progressive brain damage; and at any one time there may be 5/100,000 people in that state. However, the evidence is very limited in quality and quantity. The numbers may be greater

Multi‐disciplinary rehabilitation for acquired brain injury in adults of working age

Background. Evidence from systematic reviews demonstrates that multi-disciplinary rehabilitation is effective in the stroke population, in which older adults predominate. However, the evidence base for the effectiveness of rehabilitation following acquired brain injury (ABI) in younger adults has not been established, perhaps because this scenario presents different methodological challenges in research. Objectives. To assess the effects of multi-disciplinary rehabilitation following ABI in adults 16 to 65 years of age. Search methods. We ran the most recent search on 14 September 2015. We searched the Cochrane Injuries Group Specialised Register, The Cochrane Library, Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic+Embase (OvidSP), Web of Science (ISI WOS) databases, clinical trials registers, and we screened reference lists. Selection criteria. Randomised controlled trials (RCTs) comparing multi-disciplinary rehabilitation versus routinely available local services or lower levels of intervention; or trials comparing an intervention in different settings, of different intensities or of different timing of onset. Controlled clinical trials were included, provided they met pre-defined methodological criteria. Data collection and analysis. Three review authors independently selected trials and rated their methodological quality. A fourth review author would have arbitrated if consensus could not be reached by discussion, but in fact, this did not occur. As in previous versions of this review, we used the method described by Van Tulder 1997 to rate the quality of trials and to perform a 'best evidence' synthesis by attributing levels of evidence on the basis of methodological quality. Risk of bias assessments were performed in parallel using standard Cochrane methodology. However, the Van Tulder system provided a more discriminative evaluation of rehabilitation trials, so we have continued to use it for our primary synthesis of evidence. We subdivided trials in terms of severity of brain injury, setting and type and timing of rehabilitation offered. Main results. We identified a total of 19 studies involving 3480 people. Twelve studies were of good methodological quality and seven were of lower quality, according to the van Tulder scoring system. Within the subgroup of predominantly mild brain injury, 'strong evidence' suggested that most individuals made a good recovery when appropriate information was provided, without the need for additional specific interventions. For moderate to severe injury, 'strong evidence' showed benefit from formal intervention, and 'limited evidence' indicated that commencing rehabilitation early after injury results in better outcomes. For participants with moderate to severe ABI already in rehabilitation, 'strong evidence' revealed that more intensive programmes are associated with earlier functional gains, and 'moderate evidence' suggested that continued outpatient therapy could help to sustain gains made in early post-acute rehabilitation. The context of multi-disciplinary rehabilitation appears to influence outcomes. 'Strong evidence' supports the use of a milieu-oriented model for patients with severe brain injury, in which comprehensive cognitive rehabilitation takes place in a therapeutic environment and involves a peer group of patients. 'Limited evidence' shows that specialist in-patient rehabilitation and specialist multi-disciplinary community rehabilitation may provide additional functional gains, but studies serve to highlight the particular practical and ethical restraints imposed on randomisation of severely affected individuals for whom no realistic alternatives to specialist intervention are available. Authors' conclusions. Problems following ABI vary. Consequently, different interventions and combinations of interventions are required to meet the needs of patients with different problems. Patients who present acutely to hospital with mild brain injury benefit from follow-up and appropriate information and advice. Those with moderate to severe brain injury benefit from routine follow-up so their needs for rehabilitation can be assessed. Intensive intervention appears to lead to earlier gains, and earlier intervention whilst still in emergency and acute care has been supported by limited evidence. The balance between intensity and cost-effectiveness has yet to be determined. Patients discharged from in-patient rehabilitation benefit from access to out-patient or community-based services appropriate to their needs. Group-based rehabilitation in a therapeutic milieu (where patients undergo neuropsychological rehabilitation in a therapeutic environment with a peer group of individuals facing similar challenges) represents an effective approach for patients requiring neuropsychological rehabilitation following severe brain injury. Not all questions in rehabilitation can be addressed by randomised controlled trials or other experimental approaches. For example, trial-based literature does not tell us which treatments work best for which patients over the long term, and which models of service represent value for money in the context of life-long care. In the future, such questions will need to be considered alongside practice-based evidence gathered from large systematic longitudinal cohort studies conducted in the context of routine clinical practice

SleepSure: A pilot randomised controlled trial to assess the effects of eye masks and earplugs on the quality of sleep for patients in hospital

Objective. To determine the short-term effects of supplying hospital inpatients with earplugs and eye masks, preparatory to a full-scale trial. Design. A single centre open-label, two-arm, parallel group, randomised controlled trial. Setting. Thirteen medical and surgical wards in a large teaching hospital in the United Kingdom. Participants. Everyone admitted to hospital aged 18 years or older, who stayed overnight, and had the mental capacity and sufficient understanding of English to give consent, the ability to complete the study questionnaire, and the ability to use earplugs and eye masks unaided was considered. Interventions. The intervention group were provided with earplugs and eye masks for use the following night, and the control group received standard care. Main measures. Sleep quality assessed using the SleepSure questionnaire after the first night of using the intervention; use of earplugs and eye masks; number of falls throughout their inpatient stay; use of zopiclone during inpatient stay; length of stay; recruitment rate. Results.1,600 patients admitted, 626 (39%) eligible, 206 (13% total, 33% eligible) recruited (intervention group, 109). The intervention group’s mean sleep quality score was 6·33 (95% CI: 5·89 to 6·77), compared with 5·09 (95% CI 4·66 to 5·52) in the control group (p<0·001]. There were no differences in use of zopiclone, falls, or length of stay between the groups. Ninety-one (86%) of the intervention group reported using the earplugs and/or eye masks. Conclusions. The intervention seems feasible, and effective, but trial eligibility rate and rate of recruitment into the study were limited

‘Stand still … , and move on’, a new early intervention service for cardiac arrest survivors and their caregivers: rationale and description of the intervention

This series of articles for rehabilitation in practice aims to cover a knowledge element of the rehabilitation medicine curriculum. Nevertheless they are intended to be of interest to a multidisciplinary audience. The competency addressed in this article is ‘The trainee demonstrates a knowledge of diagnostic approaches for specific impairments including cognitive dysfunction as a result of cardiac arrest.