Neurobehavioral Function in Adults Recovering Consciousness after Severe Traumatic Brain Injury: A Scoping Review

This scoping review aims to report the findings of current literature examining the assessment of neurobehavioral function and recovery along the continuum of disorders of consciousness (DOC) from coma to full consciousness. •This study is designed to capture the range of constructs researchers have used to measure NBF during recovery of consciousness. •The research question for this review was: “What constructs are most frequently used to assess neurobehavioral function in adults recovering consciousness after severe TBI?

Communication Among Multidisciplinary Team Members Treating Patients with Disorders of Consciousness Following Traumatic Brain Injury

The purpose of this research is to understand how clinicians who work with patients with disorders of consciousness (DoC) following traumatic brain injury (TBI) communicate about patients’ behavior regarding changes in consciousness. Communication and collaboration among multidisciplinary teams is central for person-centered rehabilitation and clinical progress. A deficiency in person-centeredness may decrease the quality of care a patient receives (Epstein & Street, 2007). This process is more complicated in patients with DoC since these patients are unable to participate in the dialog (Papadimitriou & Cott, 2015). This qualitative analysis explores unique challenges clinicians face communicating with team members when treating patients with DoC following TBI in inpatient rehabilitation. A grounded theory interview study explored how clinician’s perceive they communicate patients’ changes in consciousness with team members (Green & Thorogood, 2014). Three hospital systems recruited twenty-one clinicians who have experience working with DoC patients. Clinicians participated in semi-structured interviews with two trained interviewers. Interviews were audio-recorded, transcribed verbatim, and NVivo 11 Plus software was used for open coding. The team developed a codebook using thematic analysis and constant comparative strategies to finalize the codebook (Glaser, 1965). Three major themes emerged: 1) clinicians’ difficulty interpreting patients’ behaviors of change in consciousness, 2) a lack of confidence when selecting a treatment, and 3) an uncertainty of how to leverage caregivers’ interpretation of patients’ behaviors. For example, the data describes challenges clinical teams face in discharge planning. A social worker perceives the caregiver to agree on what it takes to bring their family member home while the occupational therapist did not share this perception. The social worker tried to convey to the team that the caregiver was equipped to take the patient home, “I was turning blue in the face communicating to the team that I did strongly feel that his [caregiver] had a reasonable expectation and an understanding of the severity of his deficit”. This exemplifies how each discipline has a different vantage point surrounding a complex task such as discharge planning. Communication challenges for clinicians treating patients with DoC were grounded within the three themes, which conveyed uncertainty with interpreting patients’ behaviors and linking it to clinical progress, a lack of research to support interventions, and being cautious when talking to family. Uncovering how clinicians make sense of patient’s behaviors and how they communicate these behaviors can aide in creating a foundation for improving the exchange of information and person-centered rehabilitation

Prescribing Multiple Neurostimulants during Rehabilitation for Severe Brain Injury.

Background. Despite a lack of clear evidence, multiple neurostimulants are commonly provided after severe brain injury (BI). The purpose of this study is to determine if the number of neurostimulants received during rehabilitation was associated with recovery of full consciousness or improved neurobehavioral function after severe BI. Method. Data from 115 participants were extracted from a neurobehavioral observational study database for this exploratory, retrospective analysis. Univariate optimal data analysis was conducted to determine if the number of neurostimulants influenced classification of four outcomes: recovery of full consciousness during rehabilitation, recovery of full consciousness within one year of injury, and meaningful neurobehavioral improvement during rehabilitation defined as either at least a 4.7 unit (minimal detectable change) or 2.58 unit (minimal clinically important difference) gain on the Disorders of Consciousness Scale-25 (DOCS-25). Results. Number of neurostimulants was not significantly (P \u3e 0.05) associated with recovery of full consciousness during rehabilitation, within one year of injury, or meaningful neurobehavioral improvement using the DOCS-25. Conclusions. Receiving multiple neurostimulants during rehabilitation may not influence recovery of full consciousness or meaningful neurobehavioral improvement. Given costs associated with additional medication, future research is needed to guide physicians about the merits of prescribing multiple neurostimulants during rehabilitation after severe BI

Psychometric Properties of the Coma Near-Coma Scale for Adults in Disordered States of Consciousness: A Rasch Analysis

© 2020 American Congress of Rehabilitation Medicine Objectives: To examine the construct validity and measurement precision of the Coma Near-Coma scale (CNC) in measuring neurobehavioral function (NBF) in patients with disorders of consciousness receiving postacute care rehabilitation. Design: Rasch analysis of retrospective data. Participants: Participants (N=48) with disordered consciousness who were admitted to postacute care rehabilitation. Interventions: Not applicable. Main Outcome Measure: CNC. Results: Assessment with CNC repeated weekly until the participant was conscious or discharged from the postacute care facility (451 participant records). Rating scale steps were ordered for all items. Eight of the 10 CNC items evaluated in this study fit the measurement model (χ2=5332.58; df=11; P=.17); pain items formed a distinct construct. The ordering of the 8 items from most to least challenging makes clinical sense and compares favorably with other published hierarchies of NBF. Tactile items are more easily responded to. Visual and auditory items requiring higher cognitive processing were more challenging. In the full sample, the CNC achieved good measurement precision, with a person separation reliability of 0.87. Conclusions: The items of the CNC reflect good construct validity and acceptable interrater reliability. The measurement precision achieved indicates that the CNC may be used to make decisions about groups of individuals but that these items may not be sufficiently precise for individual patient treatment decision-making

Fluctuation is the norm : Rehabilitation practitioner perspectives on ambiguity and uncertainty in their work with persons in disordered states of consciousness after traumatic brain injury

The purpose of this study is to describe the clinical lifeworld of rehabilitation practitioners who work with patients in disordered states of consciousness (DoC) after severe traumatic brain injury (TBI). We interviewed 21 practitioners using narrative interviewing methods from two specialty health systems that admit patients in DoC to inpatient rehabilitation. The overarching theme arising from the interview data is Experiencing ambiguity and uncertainty in clinical reasoning about consciousness when treating persons in DoC. We describe practitioners\u27 practices of looking for consistency, making sense of ambiguous and hard to explain patient responses, and using trial and error or tinkering to care for patients. Due to scientific uncertainty about diagnosis and prognosis in DoC and ambiguity about interpretation of patient responses, working in the field of DoC disrupts the canonical meaning-making processes that practitioners have been trained in. Studying the lifeworld of rehabilitation practitioners through their story-making and story-telling uncovers taken-for-granted assumptions and normative structures that may exist in rehabilitation medical and scientific culture, including practitioner training. We are interested in understanding these canonical breaches in order to make visible how practitioners make meaning while treating patients