Awakening from coma: Assessment and stimulation in a Post-Critical Care Rehabilitation Units (PCCRU)

Brain injured patients who have suffered a coma require important medical supervision with a coordinated program of rehabilitation and are most likely to benefit from Post-Critical Care Rehabilitation Units (PCCRU). For these patients, an important challenge is to recognize signs of awareness beyond wakefulness. This evaluation is necessary to establish a diagnosis of the disorder of consciousness: vegetative state (VS) or unresponsive wakefulness syndrome versus minimally conscious state (MCS). Daily clinical observations of patients by trained caregivers confer to these particular environments an expertise in this field. The use of specific scales such as the Coma Recovery Scale Revised (CRS-R) allows the standardization of practices and provides quantitative data that are useful to follow patients, to assess the beneficial effect of a treatment or to compare patients. Neurophysiology and functional imagery can be used to search for markers of high-level brain activity. These tools are mostly used in research areas but can provide information complementary to the clinical evaluation, which involves a degree of subjectivity. Detecting awareness requires that patients are comfortable and because of the fluctuation of awareness, a sufficient time of observation is essential. A favorable atmosphere to promote the emergence of awareness comprises personalized stimulations such as sensory regulation programs. Music, noninvasive brain stimulations and several drugs can also boost awareness detection. A program integrating these practices is proposed to patients awakening from coma or for a specific assessment before the admission in dedicated units for patients in VS/MCS

Behavioral and affective disorders after brain injury: French guidelines for prevention and community supports

AbstractObjectiveThe purpose of this study was to elaborate practice guidelines for the prevention of behavioral and affective disorders in adult outpatients after traumatic brain injury (TBI); but also to identify the support systems available for family, caregivers of patients with TBI within the community.MethodsThe elaboration of these guidelines followed the procedure validated by the French health authority for good practice recommendations, close to the Prisma statement. This involved a systematic and critical review of the literature looking for studies that investigated the impact of programs in community settings directed to behavioral and affective disorders post-TBI. Recommendations were than elaborated by a group of professionals and family representatives.ResultsOnly six articles were found comprising 4 studies with a control group. Two studies showed a beneficial effect of personalized behavior management program delivered within natural community settings for persons with brain injury and their caregivers. Two other studies showed the relevance of scheduled telephone interventions to improve depressive symptoms and one study emphasized the usefulness of physical training. One study investigated the relevance of an outreach program; this study showed an improvement of the patients’ independence but did not yield any conclusions regarding anxiety and depression.Discussion and recommendationsIn addition to the application of care pathways already established by the SOFMER, prevention of behavioral and affective disorders for brain-injured outpatients should involve pain management, as well as development of therapeutic partnerships. It is recommended to inform patients, their family and caregivers regarding the local organization and facilities involved in the management of traumatic brain injury. The relevance of therapeutic education for implementing coping strategies, educating caregivers on behavioral disorder management, follow-up telephone interventions, and holistic therapy seems established. The level of evidence is low and preliminary studies should be confirmed with larger controlled trials

Long-term change in nutritional status after severe traumatic brain injury

IntroductionIn the acute phase, patients who sustained a severe Traumatic Brain injury (TBI) (Glasgow Coma Scale under 8) frequently present malnutrition during critical care. Long-term nutritional outcome after a severe TBI has been less studied. Cognitive impairments and behavioural disorders together with hormonal disorders can lead to persisting malnutrition or over-eating and obesity. The purpose of this study was to follow the weight, the body mass index (BMI), albuminemia and hormonal dosage after a severe TBI.MethodsThis study relied on a research protocol designed to follow concurrently and prospectively endocrine disorders and cognitive disorders in a cohort of patients with severe TBI (Inspire-TC protocol). In the present work, we focused specifically on the evolution in weight, height, body mass index, albuminemia and endocrine abnormalities. These parameters were collected upon admission to the rehabilitation department, at 4 months, 12 months and 18 months when feasible for the severe TBI patients included in the Inspire-TC protocol. Albuminaemia was measured late after the TBI when patients agreed.Results10 patients were included. Initially 60% of the patients had biological malnutrition, 10% were overweight, 80% presented a normal BMI and 10% had an insufficient BMI. All patients gained weight during the monitoring with an overweight at 18 months for three patients. Along the overall monitoring, 44% of the patients had hormonal disruptions. The 3 patients with long-term overweight had frontal-temporal brain lesions. All three recovered walking. Only one had hormonal disruptions. Albuminaemia was normal for all patients who accepted to make this bioessay control.ConclusionThere is a tendency to gain weight after a severe TBI. Favorable factors include fronto-temporal injuries, and the presence of executive disorders. Endocrine perturbation and immobility can also contribute to overweight but were less frequently observed in this cohort

Physical and rehabilitation medicine (PRM) care pathways: Adults with severe traumatic brain injury

AbstractThis document is part of a series of guidelines documents designed by the French Physical and Rehabilitation Medicine Society (SOFMER) and the French Federation of PRM (FEDMER). These reference documents focus on a particular pathology (here patients with severe TBI). They describe for each given pathology patients’ clinical and social needs, PRM care objectives and necessary human and material resources of the pathology-dedicated pathway. ‘Care pathways in PRM’ is therefore a short document designed to enable readers (physician, decision-maker, administrator, lawyer, finance manager) to have a global understanding of available therapeutic care structures, organization and economic needs for patients’ optimal care and follow-up. After a severe traumatic brain injury, patients might be divided into three categories according to impairment's severity, to early outcomes in the intensive care unit and to functional prognosis. Each category is considered in line with six identical parameters used in the International Classification of Functioning, Disability and Health (World Health Organization), focusing thereafter on personal and environmental factors liable to affect the patients’ needs

Alertness and visuospatial attention in clinical depression

<p>Abstract</p> <p>Background</p> <p>Cognitive deficits are a substantial burden in clinical depression. The present study considered dysfunction in the right-hemispheric attention network in depression, examining alertness and visuospatial attention.</p> <p>Methods</p> <p>Three computerized visuospatial attention tests and an alertness test were administered to 16 depressive patients and 16 matched healthy controls.</p> <p>Results</p> <p>Although no significant group effect was observed, alertness predicted reduced visuospatial performance in the left hemifield. Furthermore, sad mood showed a trend towards predicting left visual field omissions.</p> <p>Conclusions</p> <p>Decreased alertness may lead to lower left hemifield visuospatial attention; this mechanism may be responsible for a spatial bias to the right side in depression, even though treatment of depression and anxiety may reduce this cognitive deficit.</p