Behavioral Recovery and Early Decision Making in Patients with Prolonged Disturbance in Consciousness after Traumatic Brain Injury

The extent of behavioral recovery that occurs in patients with traumatic disorders of consciousness (DoC) following discharge from the acute care setting has been under-studied and increases the risk of overly pessimistic outcome prediction. The aim of this observational cohort study was to systematically track behavioral and functional recovery in patients with prolonged traumatic DoC following discharge from the acute care setting. Standardized behavioral data were acquired from 95 patients in a minimally conscious (MCS) or vegetative state (VS) recruited from 11 clinic sites and randomly assigned to the placebo arm of a previously completed prospective clinical trial. Patients were followed for 6 weeks by blinded observers to determine frequency of recovery of six target behaviors associated with functional status. The Coma Recovery Scale-Revised and Disability Rating Scale were used to track reemergence of target behaviors and assess degree of functional disability, respectively. Twenty percent (95% confidence interval [CI]: 13-30%) of participants (mean age 37.2; median 47 days post-injury; 69 men) recovered all six target behaviors within the 6 week observation period. The odds of recovering a specific target behavior were 3.2 (95% CI: 1.2-8.1) to 7.8 (95% CI: 2.7-23.0) times higher for patients in MCS than for those in VS. Patients with preserved language function ("MCS+") recovered the most behaviors (p ≤ 0.002) and had the least disability (p ≤ 0.002) at follow-up. These findings suggest that recovery of high-level behaviors underpinning functional independence is common in patients with prolonged traumatic DoC. Clinicians involved in early prognostic counseling should recognize that failure to emerge from traumatic DoC before 28 days does not necessarily portend unfavorable outcome

Leitlinienbasierte Standards zur Struktur- und Prozessqualität neuropsychologischer Diagnostik und Therapie

Die vorliegende Arbeit untersucht die aktuelle wissenschaftliche Evidenz zur Diagnostik und Therapie neuropsychologischer Störungen nach Hirnschädigung, wie sie bis 2020 in Leitlinien publiziert wurde. Deren Umsetzung ist nur möglich, wenn die institutionellen Rahmenbedingungen dies erlauben. Unter Einbezug der klinischen Erfahrung wurden daher auf Basis der Leitlinien Standards für eine wissenschaftlich fundierte neuropsychologische Diagnostik und Therapie erarbeitet. Es entstanden Best-Practice-Empfehlungen zu Strukturund Prozessqualität, insbesondere zu Intensität und Häufigkeit der Interventionen. Diese werden für die wichtigsten neuropsychologischen Funktionsbereiche vorgestellt. Sowohl die Deutsche Gesellschaft für Neuropsychologie e. V. (GNP) als auch die Deutsche Gesellschaft für Neurologie e. V. (DGN) unterstützen diese Empfehlungen. Sie richten sich an Neuropsycholog_innen sowie an Einrichtungsleitende und Sozialversicherungsträger und definieren die Rahmenbedingungen für eine auf den individuellen Fall angepasste leitliniengerechte neuropsychologische Behandlung.Recent years have seen the establishment of evidence-based guidelines for neuropsychological diagnostics and therapy; however, implementing these guidelines depends on structures and processes necessary to enable essential aspects like therapy frequency and intensity. The present work examines the current scientific evidence for the neuropsychological treatment of traumatic and nontraumatic brain injury, as published in guidelines up to 2020. Standards for evidence-based neuropsychological diagnostics and therapy were developed on this basis, including clinical experience and additional literature research. Best-practice recommendations on both general and specific structural and process quality emerged, especially on the intensity and frequency of interventions. These are presented for the most important neuropsychological functional areas. The German Neuropsychological Society (GNP) and the German Society for Neurology (DGN) support these recommendations. They are aimed at neuropsychologists as well as facility managers and social insurance providers, and they define the framework for guideline-based neuropsychological treatment adapted to individual cases

Neurorehabilitation for people with disorders of consciousness: an international survey of health-care structures and access to treatment, (Part 1).

peer reviewed[en] AIMS: The provision of rehabilitation services for people with disorders of consciousness (DoC) may vary due to geographical, financial, and political factors. The extent of this variability and the implementation of treatment standards across countries is unknown. This study explored international neurorehabilitation systems for people with DoC. METHODS: An online survey (SurveyMonkey®) was disseminated to all members of the International Brain Injury Association (IBIA) DoC Special Interest Group (SIG) examining existing rehabilitation systems and access to them. RESULTS: Respondents (n = 35) were from 14 countries. Specialized neurorehabilitation was available with varying degrees of access and duration. Commencement of specialized neurorehabilitation averaged 3-4 weeks for traumatic brain injury (TBI) and 5-8 weeks for non-traumatic brain injury (nTBI) etiologies. Length of stay in inpatient rehabilitation was 1-3 months for TBI and 4-6 months for nTBI. There were major differences in access to services and funding across countries. The majority of respondents felt there were not enough resources in place to provide appropriate neurorehabilitation. CONCLUSIONS: There exists inter-country differences for DoC neurorehabilitation after severe acquired brain injury. Further work is needed to implement DoC treatment standards at an international level

Development and validation of a new assessment procedure for disorders of consciousness (IDB)

Zum jetzigen Zeitpunkt gibt es keine Untersuchungsverfahren, die konsens-basierte Empfehlungen zur Differentialdiagnostik von Schädel-Hirn-verletzten Patienten mit Bewusstseinsstörungen in ausreichendem Maße berücksichtigen. In dieser Arbeit wird die Validierung eines neuen Verfahrens, des Instruments zur Differentialdiagnostik von Bewusstseinsstörungen (IDB), beschrieben. Bewusstseinsgestörte Patienten einer neurologischen Frührehabilitationseinrichtung (29 männlich und 11 weiblich) wurden mit dem IDB sowie der Disability Rating Scale (DRS) und der Coma-Remission Scale-Revised (CRS-R) zum Zeitpunkt der Aufnahme und der Entlassung aus der Klinik untersucht. Mit dem IDB ist eine diagnostische Einstufung als Wachkoma (Vegetative State, VS), minimal bewusster Zustand (MCS) oder bewusst bei allen Patienten unabhängig von der Krankheitsätiologie möglich. Die Summenscores des IDB zeigten eine hohe Korrelation mit denen der DRS und CRS-R. Bei 6 von der CRS-R als VS eingestuften Patienten konnten mit dem IDB kognitive Verarbeitungskompetenzen nachgewiesen werden. Der initiale IDB-, DRS- und CRS-R-Wert waren signifikante Prädiktoren für das Kurzzeitoutcome. Das IDB ist ein valides, reliables und im Vergleich zur CRS-R und DRS sensibleres Verfahren zur Differentialdiagnostik von Bewusstseinsstörungen und eignet sich zur Vorhersage des Behandlungserfolgs. Zweitveröffentlichung einer Dissertation.There has been a lack of diagnostic tools that sufficiently incorporate consens-based recommendations regarding the assessment of brain-injured patients with disorders of consciousness. A new assessment tool, the instrument for assessment of disorders of consciousness (IDB) was validated in this study. Patients of a neurologic rehabilitation unit with impaired consciousness after brain damage (29 male and 11 female) were examined at admission and discharge, using the IDB, the Disability Rating Scale (DRS) and the Coma-Remission Scale-Revised (CRS-R). Differential diagnosis of the disorder of consciousness (Vegetative State (VS), Minimally Conscious State (MCS), conscious) was possible, using the IDB, for all etiology groups. There was a high correlation between the IDB, DRS and CRS-R scores, though the IDB results revealed conscious activity in 6 patients who were diagnosed as VS based on CRS-R. Initial IDB-, CRS-R and DRS-results are significant predictors of short term outcome. The IDB is a valid and sensitive tool for differential diagnosis of disorders of consciousness and is predictive with regard to short-term rehabilitation outcome. Secondary publication of a thesis

A European survey about needs and beliefs of healthcare and family caregivers regarding pain assessment and management in DOC patients.

Due to the absence of communication, care for patients with disorders of consciousness (DOC) is an important clinical and ethical issue, especially for pain assessment and management. In this survey we aim to investigate the needs and beliefs of patients’ relatives and caregivers regarding pain assessment and management. By allowing a better understanding of their expectations this study could improve the management of pain in this sensitive population and decrease psychological distress of health professionals, caregivers and families.. To this end we developed an online survey that will be diffused through 40 institutions in Europe involved in the management of DOC patients. ,. The questionnaire will be divided in 2 sections: a first part to collect respondents’ socio-demographic information (e.g., age, gender, country of residence, nationality, religion, current work, year of experience with DOC patient; in compliance with the GDPR regulation) and a second part collecting data to understand the respondents’ knowledge and expectations on pain assessment and management of DOC patients (e.g., questions regarding pain perception in DOC patient, behavioural signs of pain, pain assessment tools, pain treatment). The study will last about 15 minutes and adapted according to the group (i.e., healthcare or family member). Chi-square tests will assess differences between the proportions of answers depending on the following variables: gender, profession, religion, and years of expertise or living with DOC patients. Based on the answers, we aim to develop guidelines to improve pain management and assessments for families and caregivers of DOC patients

Assessment of nociception and pain in participants with unresponsive or minimally conscious state after acquired brain injury: the relationship between the Coma Recovery Scale-Revised and the Nociception Coma Scale-Revised

Objectives: To investigate the relation between consciousness and nociceptive responsiveness (ie, Nociception Coma Scale–Revised [NCS-R]), to examine the suitability of the NCS-R for assessing nociception in participants with disorders of consciousness (DOC), and to replicate previous findings on psychometric properties of the scale. Design: Specialized DOC program. Setting: Specialized DOC program and university hospitals. Participants: Participants (N=85) diagnosed with DOC. Interventions: Not applicable. Main Outcome Measures: We prospectively assessed consciousness with the Coma Recovery Scale–Revised (CRS-R). Responses during baseline, non-noxious, and noxious stimulations were scored with the NCS-R and CRS-R oromotor and motor subscales. Results: CRS-R total scores correlated with NCS-R total scores and subscores. CRS-R motor subscores correlated with NCS-R total scores and motor subscores, and CRS-R oromotor subscores correlated with NCS-R total scores as well as verbal and facial expression subscores. There was a difference between unresponsive wakefulness syndrome and minimally conscious state in the proportion of grimacing and/or crying participants during noxious conditions. We replicated previous findings on psychometric properties of the scale but found a different score as the best threshold for nociception. Conclusions: We report a strong relation between the responsiveness to nociception and the level of consciousness. The NCS-R seems to be a valuable tool for assessing nociception in an efficient manner, but additional studies are needed to allow recommendations for clinical assessment of subjective pain experience. © 2018 American Congress of Rehabilitation Medicin