Locked-In Syndrome: Practical Rehabilitation Management

Locked-in syndrome: A qualitative study of a life story

INTRODUCTION

Locked-in syndrome (LIS) is characterized by tetraplegia, anarthria, paralysis of cranial nerves, and facial musculature, with the preservation of consciousness and cognitive abilities, as well as vertical eye movements and eyelid movements, hearing, and breathing. Three types of LIS are distinguished: classic, incomplete, and total. The aim of the present study was to describe the life history of a person with LIS, as well as the wife's experience and perspective of this life history.

METHODS

A qualitative life history study was conducted with two participants: a 54-year-old man diagnosed with LIS and his 50-year-old wife. Data were collected through interviews and autobiographical documents submitted by the participants and analyzed following Braun and Clarke's method of inductive thematic analysis.

RESULTS

Five main themes were identified: (1) how to understand and overcome the new situation; (2) the process of care and rehabilitation; (3) communication; (4) writing as a way of helping oneself and others; and (5) personal autonomy and social participation.

CONCLUSION

The participants valued the support of their friends and family in the acceptance stage of the new situation, giving special importance to the communication skills and medical attention received after diagnosis.

Feasibility of overground exoskeleton gait training during inpatient rehabilitation after severe acquired brain injury

OBJECTIVE

To describe the safety, feasibility, and tolerability of overground exoskeleton gait training (OEGT) integrated into clinical practice for patients after severe acquired brain injury (ABI).

SETTING

Inpatient rehabilitation hospital.

PARTICIPANTS

Eligible patients with severe ABI met the following criteria: age > 18, medically stable, met exoskeleton frame limitations, and a score of ≤ 3 on the motor function portion of the Coma Recovery Scale - Revised (CRS-R). Presence of consciousness disorder was not exclusionary.

DESIGN

Prospective observational study.

MAIN MEASURES

Outcomes examined safety (adverse events), feasibility (session count and barriers to session completion), and tolerability of OEGT (session metrics and heart rate).

RESULTS

Ten patients with ABI completed 10.4 ± 4.8 OEGT sessions with no adverse events. Barriers to session completion included clinical focus on prioritized interventions. Sessions [median up time = 17 minutes, (IQR: 7); walk time = 13 minutes, (IQR: 9); step count = 243, (IQR: 161); device assist = 74, (IQR: 28.0)] were primarily spent in Very Light to Light heart rate intensities [89%, (IQR: 42%) and 9%, (IQR: 33%), respectively].

CONCLUSION

OEGT incorporated into the rehabilitation plan of care during inpatient rehabilitation after severe ABI was observed to be safe, feasible, and tolerable. However, intentional steps must be taken to facilitate patient safety.

How is family health related to health-related quality of life among middle-aged and older adults in rural China? A cross-sectional study

BACKGROUND

Health-related quality of life (HRQOL) is unequal between countries and regions, and the emphasis on HRQOL of populations of low-income countries and regions is unprecedented.

OBJECTIVES

To examine the association between family health and HRQOL among middle-aged and older adults in rural China, and determine whether this association differs by age, gender and chronic disease subgroup.

METHODS

Cross-sectional survey carried out from July to September 2021. The participants were 1059 people aged 46 and over living in rural China. We used the European Quality of Life Five Dimension Five Level (EQ-5D-5L) and Family Health Scale-Short Form (FHS-SF) to assess health-related quality of life (HRQOL) and family health, respectively.

RESULTS

The mean EQ-VAS was 75.66, the mean EQ index score was 0.92, and the mean FHS was 37.90 in rural middle-aged and older adults. After Bonferroni correction, generalised linear regression models showed that FHS was significantly associated with the EQ-VAS (β = 0.829; 95% confidence interval [CI]: 0.660 to 0.997; p < .001) and the EQ index score (β = 0.003; 95%CI: 0.001 to 0.004; p < .001). Binary logistic regression models showed that FHS was associated with three dimensions of HRQOL (mobility, self-care and usual activities) (p < .01). Based on subgroup analyses, the effect of FHS on EQ-VAS and the EQ index score was significant in three subgroups after Bonferroni correction (p < .01), but the association between FHS and the dimensions of HRQOL differed by age, gender and chronic disease group (p > .01).

CONCLUSIONS

This study is the first to explore that family health and its dimensions are significant positive predictors of HRQOL among middle-aged and older adults in rural China. Family-based measures may have more potential and value because better family health significantly improves HRQOL.

IMPLICATIONS FOR PRACTICE

In the health strategy, the government and primary health care workers should include family health as an indicator and assess it before and after the implementation of the strategy.

Update on How to Approach a Patient with Locked-In Syndrome and Their Communication Ability

Locked-in syndrome (LIS) is a rare and challenging condition that results in tetraplegia and cranial nerve paralysis while maintaining consciousness and variable cognitive function. Once acute management is completed, it is important to work with the patient on developing a plan to maintain and improve their quality of life (QOL). A key component towards increasing or maintaining QOL within this population involves the establishment of a functional communication system. Evaluating cognition in patients with LIS is vital for evaluating patients' communication needs along with physical rehabilitation to maximize their QOL. In the past decade or so, there has been an increase in research surrounding brain-computer interfaces to improve communication abilities for paralyzed patients. This article provides an update on the available technology and the protocol for finding the best way for patients with this condition to communicate. This article aims to increase knowledge of how to enhance and manage communication among LIS patients.

The vascular locked-in and locked-in-plus syndrome: A retrospective case series

The locked-in syndrome (LiS) is defined as the loss of most voluntary muscle movements with preserved cognitive abilities due to a ventral pontine lesion. However, some patients may also have severe impairment of consciousness [locked-in plus syndrome (LiPS)]. Here we aimed to explore structural differences between LiS and LiPS patients of vascular aetiology, focusing on lesion patterns and locations to better delineate the clinical spectrum of LiS and LiPS. In this retrospective case series study, we report nine patients (two women), ages 29-74 years (median 50) with LiS and LiPS who were diagnosed between 2007 and 2021. Clinical parameters, MRI findings including the lesioned structures, and a shape feature calculation are presented for every patient. The lesioned structures were determined by a senior neuroradiologist. Two of nine patients had fully retained consciousness (LiS) and seven showed various degrees of impaired consciousness (LiPS). Lesions of LiS patients are round and confined to the pons, whereas lesions of LiPS patients are more elongated and reach neighbouring areas such as the mesencephalon, thalamus or ascending reticular activating system. Lesions involving the mesencephalon and the thalamus are strong indicators of LiPS, whereas for lesions restricted to the pons, the dorsal extension and the associated damage to the ascending reticular activating system are crucial to differentiate LiS from LiPS. Recognizing LiPS using clinical and radiological findings is important as these patients may need different therapies and care and, most importantly, should not be mistaken as unresponsive wakefulness syndrome.

Communication board in locked-in syndrome: a practical interaction method with the patient

Locked-in syndrome is a neurological condition characterized by tetraplegia, mutism, preservation of vertical eye movement, superior eyelid movement, and intact consciousness, making it impossible for the patient to communicate properly. We herein describe a case to analyze the practice of developing a method of communication for a patient with locked-in syndrome. Two communication boards were created, adapted to the Portuguese language, as well as a shortcut to inquire about the physical and emotional patient's well-being. We had difficulty with the initial communication board, due to the patient's low education level, so we adapted a new one to the patient's social context, including a shortcut to inquire about physical and emotional well-being. The communication board had a positive impact on treatment development and the patient's life.

Demographic, Medical, and Clinical Characteristics of a Population-Based Sample of Patients With Long-lasting Locked-In Syndrome

BACKGROUND AND OBJECTIVES

Patients with classic locked-in syndrome (LIS), typically caused by ventral pontine stroke, present with quadriplegia, mutism, intact consciousness, and communication skills limited to vertical gazing and/or blinking. Clinical presentations and definitions of LIS differ, especially regarding incomplete LIS. In our study, we explored the functional diversity of LIS, its outcomes, and the complexity of its course along with variations in the location of lesions and their potential significance for outcomes.

METHODS

A national cohort of patients with vascular LIS who remained in the LIS state for at least 6 weeks according to a functional definition of LIS was studied. Demographic, medical, and follow-up data, collected between 2012 and 2022, were obtained from the quality register of the Norwegian National Unit for Rehabilitation of Locked-In Syndrome. Outcomes in verbal communication, motor function, and dependency were evaluated according to criteria for being in or not in the LIS state. The modified Rankin scale and LIS motor recovery scale were applied. Descriptive analysis was performed. The relationship between lesion location and functional outcome was investigated.

RESULTS

The sample included 51 patients (median age: 55.7 years, 36 male individuals), 43 of whom had follow-up data. Ischemic stroke was the most common etiology (n = 35). Twenty-three patients had emerged from the LIS state, mostly within 2 years after onset. All but 1 patient achieved some motor improvement, whereas only 3 achieved full motor recovery, and 88% had a persistently high level of dependence. The 3-year survival rate was 87%. Five patients had an isolated pontine lesion, whereas 80% showed various lesions outside the brain stem. Patients who emerged from the LIS state had a significantly lower prevalence of lesions outside the brain stem than patients who remained in the LIS state did.

DISCUSSION

Investigating an unselected population-based sample of patients with vascular LIS offers important insights into the functional diversity of LIS. Although most patients remained severely disabled, even small improvements in function can substantially increase the potential for activity and participation. Additional lesions outside the brain stem seem to be common in long-lasting LIS and might be prognostic for remaining in the LIS state.

Locked-in syndrome revisited

The locked-in syndrome (LiS) is characterized by quadriplegia with preserved vertical eye and eyelid movements and retained cognitive abilities. Subcategorization, aetiologies and the anatomical foundation of LiS are discussed. The damage of different structures in the pons, mesencephalon and thalamus are attributed to symptoms of classical, complete and incomplete LiS and the locked-in plus syndrome, which is characterized by additional impairments of consciousness, making the clinical distinction to other chronic disorders of consciousness at times difficult. Other differential diagnoses are cognitive motor dissociation (CMD) and akinetic mutism. Treatment options are reviewed and an early, interdisciplinary and aggressive approach, including the provision of psychological support and coping strategies is favoured. The establishment of communication is a main goal of rehabilitation. Finally, the quality of life of LiS patients and ethical implications are considered. While patients with LiS report a high quality of life and well-being, medical professionals and caregivers have largely pessimistic perceptions. The negative view on life with LiS must be overthought and the autonomy and dignity of LiS patients prioritized. Knowledge has to be disseminated, diagnostics accelerated and technical support system development promoted. More well-designed research but also more awareness of the needs of LiS patients and their perception as individual persons is needed to enable a life with LiS that is worth living.