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González MC, Leguizamón F, Dei Vecchi L, Andreu M, Ferrea M. Factors influencing recovery in a pediatric sample with disorders of consciousness: insights from an observational study. Brain Inj 2024:1-9. [PMID: 38967329 DOI: 10.1080/02699052.2024.2372451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 06/20/2024] [Indexed: 07/06/2024]
Abstract
OBJECTIVE To estimate rates and time to reach emergence of consciousness from vegetative state/unresponsive wakefulness syndrome (VS/UWS), and explore factors associated with improved recovery in children and adolescents with disorders of consciousness (DoC) following severe traumatic and non-traumatic brain injury. METHODS Analytical, retrospective, cohort study. Clinical records of consecutively referred patients admitted in VS/UWS to a neurological rehabilitation institute in Argentina, between 2005 and 2021 were reviewed. Seventy children and adolescents were included in the analysis. A specialized 12-week rehabilitation program was administered, and emergence was defined by scores ≥44 points on the Western Neuro Sensory Stimulation Profile (WNSSP), sustained for at least 3 weeks on consecutive weekly evaluations. RESULTS Emergence from VS/UWS to consciousness occurred within 5.4 (SD 2.6) weeks in almost one-third of patients. Multivariate Cox regression analysis showed emergence was significantly lower in patients with hypoxic ischemic encephalopathy compared to patients with other non-traumatic etiologies [HRadj 0.23 (95% CI 0.06-0.89); p = 0.03)]. CONCLUSIONS Our findings reinforce growing evidence on the impact of etiology on DoC recovery in pediatric populations, ultimately influencing treatment and family-related decisions in child neurorehabilitation.
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Affiliation(s)
- María Cecilia González
- Fundación para la Lucha contra las Enfermedades Neurológicas de la Infancia (FLENI), Centro de Rehabilitación Infantil (CRI), Escobar, Argentina
| | - F Leguizamón
- Fundación para la Lucha contra las Enfermedades Neurológicas de la Infancia (FLENI), Centro de Rehabilitación Infantil (CRI), Escobar, Argentina
| | - L Dei Vecchi
- Fundación para la Lucha contra las Enfermedades Neurológicas de la Infancia (FLENI), Centro de Rehabilitación Infantil (CRI), Escobar, Argentina
| | - M Andreu
- Departamento de Ciencias de la Salud, Universidad Nacional de la Matanza (UNLaM), San Justo, Buenos Aires, Argentina
| | - M Ferrea
- Fundación para la Lucha contra las Enfermedades Neurológicas de la Infancia (FLENI), Centro de Rehabilitación Infantil (CRI), Escobar, Argentina
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Barra A, Monti M, Thibaut A. Noninvasive Brain Stimulation Therapies to Promote Recovery of Consciousness: Where We Are and Where We Should Go. Semin Neurol 2022; 42:348-362. [PMID: 36100229 DOI: 10.1055/s-0042-1755562] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Therapeutic options for patients with disorders of consciousness (DoC) are still underexplored. Noninvasive brain stimulation (NIBS) techniques modulate neural activity of targeted brain areas and hold promise for the treatment of patients with DoC. In this review, we provide a summary of published research using NIBS as therapeutic intervention for DoC patients, with a focus on (but not limited to) randomized controlled trials (RCT). We aim to identify current challenges and knowledge gaps specific to NIBS research in DoC. Furthermore, we propose possible solutions and perspectives for this field. Thus far, the most studied technique remains transcranial electrical stimulation; however, its effect remains moderate. The identified key points that NIBS researchers should focus on in future studies are (1) the lack of large-scale RCTs; (2) the importance of identifying the endotypes of responders; and (3) the optimization of stimulation parameters to maximize the benefits of NIBS.
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Affiliation(s)
- Alice Barra
- Coma Science Group, GIGA Consciousness - GIGA Research, University of Liège, Liège, Belgium.,Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Martin Monti
- Department of Psychology, University of California Los Angeles, Los Angeles, California.,Department of Neurosurgery, UCLA Brain Injury Research Center, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Aurore Thibaut
- Coma Science Group, GIGA Consciousness - GIGA Research, University of Liège, Liège, Belgium.,Centre du Cerveau, University Hospital of Liège, Liège, Belgium
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3
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Behavioral signs of recovery from unresponsive wakefulness syndrome to emergence of minimally conscious state after severe brain injury. Ann Phys Rehabil Med 2021; 65:101534. [PMID: 33933691 DOI: 10.1016/j.rehab.2021.101534] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 03/02/2021] [Accepted: 03/16/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND A precise description of behavioral signs denoting transition from an unresponsive wakefulness syndrome/vegetative state (UWS/VS) to minimally conscious state (MCS) or emergence from MCS after severe brain injury is crucial for prognostic purposes. A few studies have attempted this goal but involved non-standardized instruments, limited temporal accuracy or samples or focused on patients with (sub)acute condition. OBJECTIVES We aimed to describe the behavioral signs that led to a change in diagnosis as well as the factors affecting this transition in a large sample of patients with chronic disorders of consciousness after severe brain injury. METHODS In this retrospective cohort study, patients in UWS/VS or MCS were assessed with the Coma Recovery Scale Revised (CRS-R) at 5 times within the 2 weeks after their admission to a neurorehabilitation center and then weekly until emergence from MCS, discharge or death. RESULTS Of the 185 patients included, 33 in UWS/VS and 45 in MCS transitioned to another state. Transition to MCS was mostly denoted by one behavioral sign (71%), predominantly visual fixation, followed by localization to noxious stimulation, and visual pursuit, and could be predicted by etiology, time post-injury and age. Emergence from MCS was characterized by one sign in 64% of patients and by 2 signs (functional communication and objects use) in the remaining patients and could be predicted by time post-injury and number of behavioral signs at admission. CONCLUSIONS Transition from UWS to MCS was predominantly signalled by visual fixation and could be predicted by etiology, time post-injury and age. Emergence from MCS was mostly signalled by one sign and could be predicted by time post-injury and number of behavioral signs at admission. Clinicians should pay particular attention to visual and motor subscales of the CRS-R to detect behavioral recovery after severe brain injury. Database registration. ClinicalTrials.gov: NCT04687397.
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4
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Martens G, Bodien Y, Sheau K, Christoforou A, Giacino JT. Which behaviours are first to emerge during recovery of consciousness after severe brain injury? Ann Phys Rehabil Med 2019; 63:263-269. [PMID: 31783144 DOI: 10.1016/j.rehab.2019.10.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 10/26/2019] [Accepted: 10/29/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Early detection of consciousness after severe brain injury is critical for establishing an accurate prognosis and planning appropriate treatment. OBJECTIVES To determine which behavioural signs of consciousness emerge first and to estimate the time course to recovery of consciousness in patients with severe acquired brain injury. METHODS Retrospective observational study using the Coma Recovery Scale-Revised and days to recovery of consciousness in 79 patients (51 males; 34 with traumatic brain injury; median [IQR] age 48 [26-61] years; median time since injury 26 [20-36] days) who transitioned from coma or unresponsive wakefulness syndrome (UWS)/vegetative state (VS) to the minimally conscious state (MCS) or emerged from MCS during inpatient rehabilitation. RESULTS Visual pursuit was the most common initial sign of MCS (41% of patients; 95% CI [30-52]), followed by reproducible command-following (25% [16-35]) and automatic movements (24% [15-33]). Ten other behaviours emerged first in less than 16% of cases. Median [IQR] time to recovery of consciousness was 44 [33-59] days. Etiology did not significantly affect time to recovered consciousness. CONCLUSION Recovery of consciousness after severe brain injury is most often signalled by reemergence of visual pursuit, reproducible command-following and automatic movements. Clinicians should use assessment measures that are sensitive to these behaviours because early detection of consciousness is critical for accurate prognostication and treatment planning.
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Affiliation(s)
- Geraldine Martens
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, United States of America; Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States of America; Coma Science Group, GIGA Research, GIGA-Consciousness, University of Liege, 11, avenue de l'Hôpital, 4000 Liège (Sart Tilman), Belgium; Centre du Cerveau(2) - Centre intégré pluridisciplinaire de l'étude du cerveau, de la cognition et de la conscience, University Hospital of Liège, Liège, Belgium.
| | - Yelena Bodien
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, United States of America; Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States of America; Laboratory for Neuroimaging in Coma and Consciousness, Massachusetts General Hospital, Boston, MA, United States of America
| | - Kristen Sheau
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, United States of America; Massachusetts General Hospital Institute of Health Professions, Boston, MA, United States of America
| | - Andrea Christoforou
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, United States of America; Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States of America
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, United States of America; Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States of America
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5
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Zhou F, Li H, Wang K, He Y, Chen Y, Ni X, Guo Y, Lv W, Zhang J, Xie Q, Yu R. Finger or Light: Stimulation Sensitivity of Visual Startle in the Coma Recovery Scale-Revised for Disorders of Consciousness. Neurosci Bull 2018; 34:709-712. [PMID: 30019217 DOI: 10.1007/s12264-018-0261-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 06/25/2018] [Indexed: 01/12/2023] Open
Affiliation(s)
- Feng Zhou
- Coma Research Group, Center for Hyperbaric Oxygen and Neuro-rehabilitation, Neuroscience Institute, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, 510010, China.,Xiangya School of Medicine, Central South University, Changsha, 410013, China.,Department of Neurology, The First People's Hospital of Foshan, Foshan, 528000, China
| | - Hui Li
- Clinical Laboratory, The Second Chinese Traditional Medical Hospital of Guangdong Province, Guangzhou, 510095, China
| | - Kai Wang
- Department of Biostatistics, Southern Medical University, Guangzhou, 510515, China
| | - Yanbin He
- Coma Research Group, Center for Hyperbaric Oxygen and Neuro-rehabilitation, Neuroscience Institute, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, 510010, China
| | - Yan Chen
- Coma Research Group, Center for Hyperbaric Oxygen and Neuro-rehabilitation, Neuroscience Institute, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, 510010, China
| | - Xiaoxiao Ni
- Coma Research Group, Center for Hyperbaric Oxygen and Neuro-rehabilitation, Neuroscience Institute, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, 510010, China
| | - Yechun Guo
- Coma Research Group, Center for Hyperbaric Oxygen and Neuro-rehabilitation, Neuroscience Institute, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, 510010, China
| | - Wei Lv
- Coma Research Group, Center for Hyperbaric Oxygen and Neuro-rehabilitation, Neuroscience Institute, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, 510010, China
| | - Jiechun Zhang
- Coma Research Group, Center for Hyperbaric Oxygen and Neuro-rehabilitation, Neuroscience Institute, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, 510010, China
| | - Qiuyou Xie
- Coma Research Group, Center for Hyperbaric Oxygen and Neuro-rehabilitation, Neuroscience Institute, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, 510010, China
| | - Ronghao Yu
- Coma Research Group, Center for Hyperbaric Oxygen and Neuro-rehabilitation, Neuroscience Institute, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, 510010, China.
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6
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Baricich A, de Sire A, Antoniono E, Gozzerino F, Lamberti G, Cisari C, Invernizzi M. Recovery from vegetative state of patients with a severe brain injury: a 4-year real-practice prospective cohort study. FUNCTIONAL NEUROLOGY 2018; 32:131-136. [PMID: 29042001 DOI: 10.11138/fneur/2017.32.3.131] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Patients who have suffered severe traumatic or nontraumatic brain injuries can show a progressive recovery, transitioning through a range of clinical conditions. They may progress from coma to a vegetative state (VS) and/or a minimally conscious state (MCS). A longer duration of the VS is known to be related to a lower probability of emergence from it; furthermore, the literature seems to lack evidence of late improvements in these patients. This real-practice prospective cohort study was conducted in inpatients in a VS following a severe brain injury, consecutively admitted to a vegetative state unit (VSU). The aim of the study was to assess their recovery in order to identify variables that might increase the probability of a VS patient transitioning to MCS. Rehabilitation treatment included passive joint mobilisation and helping/placing patients into an upright sitting position on a tilt table. All the patients underwent a specific assessment protocol every month to identify any emergence, however late, from the VS. Over a 4-year period, 194 patients suffering sequelae of a severe brain injury, consecutively seen, had an initial Glasgow Coma Scale score ≤ 8. Of these, 63 (32.5%) were in a VS, 84 (43.3%) in a MCS, and 47 (24.2%) in a coma; of the 63 patients admitted in a VS, 49 (57.1% males and 42.9% females, mean age 25.34 ± 19.12 years) were transferred to a specialist VSU and put on a slow-to-recover brain injury programme. Ten of these 49 patients were still in a VS after 36 months; of these 10, 3 recovered consciousness, transitioning to a MCS, 2 died, and 5 remained in a VS during the last 12 months of the observation. Univariate analysis identified male sex, youth, a shorter time from onset of the VS, diffuse brain injury, and the presence of status epilepticus as variables increasing the likelihood of transition to a MCS. Long-term monitoring of patients with chronic disorders of consciousness should be adequately implemented in order to optimise their access to rehabilitation services.
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Abstract
In the 2015 David Kopf Lecture on Neuroethics of the Society for Neuroscience, Dr. Joseph Fins presents his work on neuroethics and disorders of consciousness through the experience of Maggie and Nancy Worthen, a young woman who sustained a severe brain injury and her mother who cared for her. The central protagonists in his book, Rights Come to Mind: Brain Injury, Ethics and the Struggle for Consciousness (Cambridge University Press, 2015), their experience is emblematic of the challenges faced by families touched by severe brain injury and the possibility for improved diagnosis and treatment offered by progress in neuroscience. By telling their story, and those of other families interviewed as part of the research for Rights Come to Mind, Fins calls for improved care for this population arguing that this is both an access to care issue and a civil and disability rights issue worthy of greater societal attention.
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8
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Steel J, Ferguson A, Spencer E, Togher L. Language and cognitive communication disorder during post-traumatic amnesia: Profiles of recovery after TBI from three cases. Brain Inj 2017; 31:1889-1902. [DOI: 10.1080/02699052.2017.1373200] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Joanne Steel
- Speech Pathology, The University of Newcastle, Newcastle, Australia
- NHMRC Centre of Research Excellence in Brain Recovery, Moving Ahead, Sydney, Australia
| | - Alison Ferguson
- Speech Pathology, The University of Newcastle, Newcastle, Australia
- NHMRC Centre of Research Excellence in Brain Recovery, Moving Ahead, Sydney, Australia
| | | | - Leanne Togher
- Speech Pathology, The University of Sydney, Sydney, Australia
- NHMRC Centre of Research Excellence in Brain Recovery, Moving Ahead, Sydney, Australia
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9
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Steel J, Ferguson A, Spencer E, Togher L. Social communication assessment during post-traumatic amnesia and the post-acute period after traumatic brain injury. Brain Inj 2017; 31:1320-1330. [DOI: 10.1080/02699052.2017.1332385] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Joanne Steel
- Deparment of Speech Pathology, The University of Newcastle, Newcastle, Australia
- NHMRC Centre of Research Excellence in Brain Recovery, Moving Ahead, Sydney, Australia
| | - Alison Ferguson
- Deparment of Speech Pathology, The University of Newcastle, Newcastle, Australia
- NHMRC Centre of Research Excellence in Brain Recovery, Moving Ahead, Sydney, Australia
| | - Elizabeth Spencer
- Deparment of Speech Pathology, The University of Newcastle, Newcastle, Australia
| | - Leanne Togher
- NHMRC Centre of Research Excellence in Brain Recovery, Moving Ahead, Sydney, Australia
- Deparment of Speech Pathology, The University of Sydney, Sydney, Australia
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10
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Steel J, Ferguson A, Spencer E, Togher L. Speech-language pathologists’ perspectives on cognitive communication assessment during post-traumatic amnesia. Brain Inj 2016; 30:1131-42. [DOI: 10.1080/02699052.2016.1174785] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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11
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De Tanti A, Saviola D, Basagni B, Cavatorta S, Chiari M, Casalino S, De Bernardi D, Galvani R. Recovery of consciousness after 7 years in vegetative state of non-traumatic origin: A single case study. Brain Inj 2016; 30:1029-34. [DOI: 10.3109/02699052.2016.1147078] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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12
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Cortese MD, Riganello F, Arcuri F, Pugliese ME, Lucca LF, Dolce G, Sannita WG. Coma recovery scale-r: variability in the disorder of consciousness. BMC Neurol 2015; 15:186. [PMID: 26450569 PMCID: PMC4599033 DOI: 10.1186/s12883-015-0455-5] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 10/01/2015] [Indexed: 11/10/2022] Open
Abstract
Background Despite evidence from neuroimaging research, diagnosis and early prognosis in the vegetative (VS/UWS) and minimally conscious (MCS) states still depend on the observation of clinical signs of responsiveness. Multiple testing has documented a systematic variability during the day in the incidence of established signs of responsiveness. Spontaneous fluctuations of the Coma Recovery Scale-revised (CRS-r) scores are conceivable. Methods We retrospectively analyzed the CRS-r repeatedly administered to 7 VS/UWS and 12 MCS subjects undergoing systematic observation during a conventional 13 weeks. rehabilitation plan. Results The CRS-r global, visual and auditory scores were found higher in the morning than at the afternoon administration in both VS/UWS and MCS subgroups over the entire period of observation. The probability for a VS/UWS subject of being classified as MCS at the morning testing at least once during the 13 weeks. observation was as high as 30 %, i.e., compatible with the reported misdiagnosis rate between the two clinical conditions. Conclusions Multiple CRS-r testing is advisable to minimize the risk of misclassification; estimates of spontaneous variability could be used to characterize with greater accuracy patients with disorder of consciousness and possibly help optimize the rehabilitation plan.
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Affiliation(s)
- M D Cortese
- Institute S. Anna and RAN (Research in Advanced Rehabilitation), Crotone, Italy.
| | - F Riganello
- Institute S. Anna and RAN (Research in Advanced Rehabilitation), Crotone, Italy.
| | - F Arcuri
- Institute S. Anna and RAN (Research in Advanced Rehabilitation), Crotone, Italy.
| | - M E Pugliese
- Institute S. Anna and RAN (Research in Advanced Rehabilitation), Crotone, Italy.
| | - L F Lucca
- Institute S. Anna and RAN (Research in Advanced Rehabilitation), Crotone, Italy.
| | - G Dolce
- Institute S. Anna and RAN (Research in Advanced Rehabilitation), Crotone, Italy.
| | - W G Sannita
- Department of Neuroscience, Ophthalmology and Genetics, University of Genova, 3, Largo P. Daneo, 16132, Genova, Italy. .,Department of Psychiatry, State University of New York, Stony Brook, NY, USA.
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Lancioni GE, Singh NN, O'Reilly MF, Sigafoos J, Belardinelli MO, Buonocunto F, D'Amico F, Navarro J, Lanzilotti C, Denitto F, De Tommaso M, Megna M. Supporting self-managed leisure engagement and communication in post-coma persons with multiple disabilities. RESEARCH IN DEVELOPMENTAL DISABILITIES 2015; 38:75-83. [PMID: 25546297 DOI: 10.1016/j.ridd.2014.12.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Accepted: 12/09/2014] [Indexed: 06/04/2023]
Abstract
Post-coma persons affected by extensive motor impairment and lack of speech, with or without disorders of consciousness, need special support to manage leisure engagement and communication. These two studies extended research efforts aimed at assessing basic technology-aided programs to provide such support. Specifically, Study I assessed a program for promoting independent stimulation choice in four post-coma persons who combined motor and speech disabilities with disorders of consciousness (i.e., were rated between the minimally conscious state and the emergence from such state). Study II assessed a program for promoting independent television operation and basic communication in three post-coma participants who, contrary to those involved in Study I, did not have disorders of consciousness (i.e., had emerged from a minimally conscious state). The results of the studies were largely positive with substantial levels of independent stimulation choice and access for the participants of Study I and independent television operation and communication for the participants of Study II. The results were analyzed in relation to previous data in the area and in terms of their implications for daily contexts dealing with these persons.
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Affiliation(s)
| | - Nirbhay N Singh
- Medical College of Georgia, Georgia Regents University, Augusta, USA
| | | | | | | | | | - Fiora D'Amico
- S. Raffaele Rehabilitation and Care Centers, Ceglie and Alberobello, Italy
| | - Jorge Navarro
- S. Raffaele Rehabilitation and Care Centers, Ceglie and Alberobello, Italy
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Lancioni GE, Singh NN, O'Reilly MF, Sigafoos J, Olivetti Belardinelli M, Buonocunto F, D'Amico F, Navarro J, Lanzilotti C, Ferlisi G, Denitto F. Technology-aided programs for post-coma patients emerged from or in a minimally conscious state. Front Hum Neurosci 2014; 8:931. [PMID: 25538593 PMCID: PMC4257021 DOI: 10.3389/fnhum.2014.00931] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 10/31/2014] [Indexed: 11/17/2022] Open
Abstract
Post-coma persons in a minimally conscious state (MCS) or emerged/emerging from such state (E-MCS), who are affected by extensive motor impairment and lack of speech, may develop an active role and interact with their environment with the help of technology-aided intervention programs. Although a number of studies have been conducted in this area during the last few years, new evidence about the efficacy of those programs is warranted. These three studies were an effort in that direction. Study I assessed a technology-aided program to enable six MCS participants to access preferred environmental stimulation independently. Studies II and III assessed technology-aided programs to enable six E-MCS participants to make choices. In Study II, three of those participants were led to choose among leisure and social stimuli, and caregiver interventions automatically presented to them. In Study III, the remaining three participants were led to choose (a) among general stimulus/intervention options (e.g., songs, video-recordings of family members, and caregiver interventions); and then (b) among variants of those options. The results of all three studies were largely positive with substantial increases of independent stimulation access for the participants of Study I and independent choice behavior for the participants of Studies II and III. The results were analyzed in relation to previous data and in terms of their implications for daily contexts working with MCS and E-MCS persons affected by multiple disabilities.
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Affiliation(s)
- Giulio E Lancioni
- Department of Neuroscience and Sense Organs, University of Bari Bari, Italy
| | - Nirbhay N Singh
- Medical College of Georgia, Georgia Regents University Augusta, GA, USA
| | - Mark F O'Reilly
- Department of Special Education, University of Texas at Austin Austin, TX, USA
| | - Jeff Sigafoos
- Department of Educational Psychology, Victoria University of Wellington Wellington, New Zealand
| | | | | | - Fiora D'Amico
- S. Raffaele Rehabilitation and Care Centers Ceglie and Alberobello, Italy
| | - Jorge Navarro
- S. Raffaele Rehabilitation and Care Centers Ceglie and Alberobello, Italy
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Bower J, Catroppa C, Grocke D, Shoemark H. Music therapy for early cognitive rehabilitation post-childhood TBI: an intrinsic mixed methods case study. Dev Neurorehabil 2014; 17:339-46. [PMID: 23815784 DOI: 10.3109/17518423.2013.778910] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The primary aim of this case study was to explore the behavioural changes of a paediatric patient in post-traumatic amnesia (PTA) during a music therapy session. A secondary objective was to measure the effect of the music therapy intervention on agitation. METHOD Video data from pre, during and post-music therapy sessions were collected and analysed using video micro-analysis and the Agitated Behaviour Scale. RESULTS The participant displayed four discrete categories of behaviours: Neutral, Acceptance, Recruitment and Rejection. Further analysis revealed brief but consistent and repeated periods of awareness and responsiveness to the live singing of familiar songs, which were classified as Islands of Awareness. Song offered an Environment of Potential to maximise these periods of emerging consciousness. The quantitative data analysis yielded inconclusive results in determining if music therapy was effective in reducing agitation during and immediately post the music therapy sessions. CONCLUSION The process of micro-analysis illuminated four discrete participant behaviours not apparent in the immediate clinical setting. The results of this case suggest that the use of familiar song as a music therapy intervention may harness early patient responsiveness to foster cognitive rehabilitation in the early acute phase post-TBI.
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Affiliation(s)
- Janeen Bower
- Music Therapy Department, The Royal Children's Hospital Melbourne , Flemington Rd, Parkville, VIC , Australia
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16
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Rate of Disorders of Consciousness in a Prospective Population-Based Study of Adults With Traumatic Brain Injury. J Head Trauma Rehabil 2014; 29:E31-43. [DOI: 10.1097/htr.0000000000000017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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17
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Lancioni GE, Singh NN, O'Reilly MF, Sigafoos J, Oliva D, Campodonico F, D'Amico F, Buonocunto F, Sacco V, Didden R. Post-coma persons emerging from a minimally conscious state with multiple disabilities make technology-aided phone contacts with relevant partners. RESEARCH IN DEVELOPMENTAL DISABILITIES 2013; 34:3190-3196. [PMID: 23891723 DOI: 10.1016/j.ridd.2013.06.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 06/14/2013] [Indexed: 06/02/2023]
Abstract
Post-coma individuals emerging from a minimally conscious state with multiple disabilities may enjoy contact with relevant partners (e.g., family members and friends), but may not have easy access to them. These two single-case studies assessed whether those individuals could make contact with partners through computer-aided telephone technology and enjoy such contact. The technology involved a computer system with special software, a global system for mobile communication modem (GSM), and microswitch devices. In Study I, the computer system presented a 23-year-old man the names of the partners that he could contact, one at a time, automatically. Together with each partner's name, the system also presented the voice of the partner asking the man whether he wanted to call him or her. The man could (a) place a call to that partner by activating a camera-based microswitch through mouth movements or (b) bypass that partner and wait for the next one to be presented. In Study II, the system presented a 36-year-old man the partners' names only after he had activated his wobble microswitch with a hand movement. The man could place a call or bypass a partner as in Study I. The results showed that both men (a) were able to contact relevant partners through the technology, (b) seemed to enjoy their telephone-mediated communication contacts with the partners, and (c) showed preferences among the partners. Implications of the findings are discussed.
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Lancioni GE, Singh NN, O'Reilly MF, Sigafoos J, Buonocunto F, Sacco V, Navarro J, Lanzilotti C, D'Amico F, Sasanelli G, De Tommaso M, Megna M. Technology-aided recreation and communication opportunities for post-coma persons affected by lack of speech and extensive motor impairment. RESEARCH IN DEVELOPMENTAL DISABILITIES 2013; 34:2959-2966. [PMID: 23816631 DOI: 10.1016/j.ridd.2013.06.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 06/05/2013] [Indexed: 06/02/2023]
Abstract
This study assessed technology-aided intervention programs for two post-coma men who had re-acquired consciousness, but were unable to engage in personally or socially relevant occupations, given their lack of functional speech and their extensive motor disabilities. The microswitches used for accessing the program contents consisted of (a) a pressure sensor fixed in the palm of the first man's hand that could be activated with a small hand closure movement, and (b) an optic sensor fixed under the chin of the second man that could be activated by mouth opening movements. The programs' content consisted of recreation and communication options, which involved activating music, videos, and basic requests, sending and receiving (listening to) text messages, and placing phone calls. The results showed that the men (a) used the technology-aided programs successfully to manage the recreation and communication options available and (b) showed consistent preference for the sessions with the technology-aided program over other daily events. Family and staff members interviewed about the participants' programs (seven members for each participant) thought that the participants enjoyed the intervention sessions with the programs and that the programs had beneficial effects for them. Implications of the findings are discussed.
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Steel J, Ferguson A, Spencer E, Togher L. Speech pathologists’ current practice with cognitive-communication assessment during post-traumatic amnesia: A survey. Brain Inj 2013; 27:819-30. [DOI: 10.3109/02699052.2013.775492] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
BACKGROUND The prediction of neurologic outcome is a fundamental concern in the resuscitation of patients with severe brain injury. OBJECTIVE To provide an evidence-based update on neurologic prognosis following traumatic brain injury and hypoxic-ischemic encephalopathy after cardiac arrest. DATA SOURCE Search of the PubMed database and manual review of bibliographies from selected articles to identify original data relating to prognostic methods and outcome prediction models in patients with neurologic trauma or hypoxic-ischemic encephalopathy. DATA SYNTHESIS AND CONCLUSION Articles were scrutinized regarding study design, population evaluated, interventions, outcomes, and limitations. Outcome prediction in severe brain injury is reliant on features of the neurologic examination, anatomical and physiological changes identified with CT and MRI, abnormalities detected with electroencephalography and evoked potentials, and physiological and biochemical derangements at both the brain and systemic levels. Use of such information in univariable association studies generally lacks specificity in classifying neurologic outcome. Furthermore, the accuracy of established prognostic classifiers may be affected by the introduction of outcome-modifying interventions, such as therapeutic hypothermia following cardiac arrest. Although greater specificity may be achieved with scoring systems derived from multivariable models, they generally fail to predict outcome with sufficient accuracy to be meaningful at the single patient level. Discriminative models which integrate knowledge of genetic determinants and biologic processes governing both injury and repair and account for the effects of resuscitative and rehabilitative care are needed.
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Lancioni GE, O'Reilly MF, Singh NN, Sigafoos J, Buonocunto F, Sacco V, Navarro J, Lanzilotti C, De Tommaso M, Megna M, Oliva D. Technology-aided leisure and communication opportunities for two post-coma persons emerged from a minimally conscious state and affected by multiple disabilities. RESEARCH IN DEVELOPMENTAL DISABILITIES 2013; 34:809-816. [PMID: 23220057 DOI: 10.1016/j.ridd.2012.10.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2012] [Accepted: 10/18/2012] [Indexed: 06/01/2023]
Abstract
This study assessed technology-aided programs for helping two post-coma persons, who had emerged from a minimally conscious state and were affected by multiple disabilities, to (a) engage with leisure stimuli and request caregiver's procedures, (b) send out and listen to text messages for communication with distant partners, and (c) combine leisure engagement and procedure requests with text messaging within the same sessions. The program for leisure engagement and procedure requests relied on the use of a portable computer with commercial software, and a microswitch for the participants' response. The program for text messaging communication involved the use of a portable computer, a GSM modem, a microswitch for the participants' response, and specifically developed software. Results indicated that the participants were successful at each of the three stages of the study, thus providing relevant evidence concerning performance achievements only minimally documented. The implications of the findings in terms of technology and practical opportunities for post-coma persons with multiple disabilities are discussed.
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Affiliation(s)
- Giulio E Lancioni
- Department of Neuroscience and Sense Organs, University of Bari, Italy.
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Lancioni GE, Singh NN, O'Reilly MF, Sigafoos J, Belardinelli MO, Buonocunto F, Sacco V, Navarro J, Lanzilotti C, De Tommaso M, Megna M, Badagliacca F. Promoting adaptive behavior in persons with acquired brain injury, extensive motor and communication disabilities, and consciousness disorders. RESEARCH IN DEVELOPMENTAL DISABILITIES 2012; 33:1964-1974. [PMID: 22738766 DOI: 10.1016/j.ridd.2012.05.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2012] [Accepted: 05/29/2012] [Indexed: 06/01/2023]
Abstract
These two studies extended the evidence on the use of technology-based intervention packages to promote adaptive behavior in persons with acquired brain injury and multiple disabilities. Study I involved five participants in a minimally conscious state who were provided with intervention packages based on specific arrangements of optic, tilt, or pressure microswitches (linked to preferred environmental stimuli) and eyelid, toe and finger responses. Study II involved three participants who were emerging from a minimally conscious state and were provided with intervention packages based on computer presentations of stimulus options (i.e., preferred stimuli, functional caregiver's procedures, and non-preferred stimuli) and pressure microswitches to choose among them. Intervention data of Study I showed that the participants acquired relatively high levels of microswitch responding (thus engaging widely with preferred environmental stimuli) and kept that responding consistent except for one case. Intervention data of Study II showed that the participants were active in choosing among preferred stimuli and positive caregivers' procedures, but generally abstained from non-preferred stimuli. The results were discussed in terms of the successful use of fairly new/infrequent microswitch-response arrangements (Study I) and the profitable inclusion of functional caregiver's procedures among the options available to choice (Study II).
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Affiliation(s)
- Giulio E Lancioni
- Department of Neuroscience and Sense Organs, University of Bari, Italy.
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Noé E, Olaya J, Navarro MD, Noguera P, Colomer C, García-Panach J, Rivero S, Moliner B, Ferri J. Behavioral Recovery in Disorders of Consciousness: A Prospective Study With the Spanish Version of the Coma Recovery Scale–Revised. Arch Phys Med Rehabil 2012; 93:428-33.e12. [DOI: 10.1016/j.apmr.2011.08.048] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Revised: 07/19/2011] [Accepted: 08/08/2011] [Indexed: 10/14/2022]
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Lancioni GE, Singh NN, O'Reilly MF, Sigafoos J, Colonna F, Buonocunto F, Sacco V, Megna M, Oliva D. Post-coma persons emerged from a minimally conscious state and showing multiple disabilities learn to manage a radio-listening activity. RESEARCH IN DEVELOPMENTAL DISABILITIES 2012; 33:670-674. [PMID: 22186634 DOI: 10.1016/j.ridd.2011.11.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Accepted: 11/10/2011] [Indexed: 05/31/2023]
Abstract
This study assessed microswitch-based technology to enable three post-coma adults, who had emerged from a minimally conscious state but presented motor and communication disabilities, to operate a radio device. The material involved a modified radio device, a microprocessor-based electronic control unit, a personal microswitch, and an amplified MP3 player. The study was carried out according to a non-concurrent multiple baseline design across participants. During the intervention, all three participants learned to operate the radio device, changing stations and tuning on some of them longer amounts of time than on others (i.e., suggesting preferences among the topics covered by those stations). They also ended a number of sessions before the maximum length of time allowed for them had elapsed. The practical (rehabilitation) implications of the findings were discussed.
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Dewar BK, Pickard JD, Wilson BA. Behavioural and Psychosocial Outcome Following Vegetative and Minimally Conscious States: Long-Term Follow-Up. BRAIN IMPAIR 2012. [DOI: 10.1375/brim.9.3.267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractThe long-term outcome of persons with impaired consciousness after brain injury remains relatively unclear. The first 12 months post ictus are widely reported as the period of greatest change, with an estimated 20% of persons with traumatic brain injury recovering consciousness. However, beyond 12 months post traumatic and 6 months post-nontraumatic injury the chances of further recovery are thought to diminish significantly. The aim of this study was to investigate the behavioural and psychosocial outcome of 12 patients with impaired consciousness 2 years post ictus. At the time of recruitment five of these patients met the diagnostic criteria defining the vegetative state and seven of these patients met the diagnostic criteria defining the minimally conscious state. Patients were assessed using the Wessex Head Injury Matrix at recruitment and again at least 2 years after initial contact. Functional and psychosocial outcome were also explored. Most patients showed some improvements to their behavioural portfolio, but all were still very dependent physically and all required a high level of support in their activities of daily living. None of the patients had emerged from their original condition, despite exhibiting larger behavioural portfolios. The implications of these findings for the management of patients in low awareness states are discussed.
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Candelieri A, Cortese MD, Dolce G, Riganello F, Sannita WG. Visual Pursuit: Within-Day Variability in the Severe Disorder of Consciousness. J Neurotrauma 2011; 28:2013-7. [PMID: 21770758 DOI: 10.1089/neu.2011.1885] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Affiliation(s)
- Antonio Candelieri
- S. Anna Institute and Research in Advanced Neurorehabilitation (RAN), Crotone, University of Calabria, Cosenza, Italy
- Laboratory of Decision Engineering for Healthcare Delivery, Department of Electronics Informatics and Systems, University of Calabria, Cosenza, Italy
| | - Maria Daniela Cortese
- S. Anna Institute and Research in Advanced Neurorehabilitation (RAN), Crotone, University of Calabria, Cosenza, Italy
| | - Giuliano Dolce
- S. Anna Institute and Research in Advanced Neurorehabilitation (RAN), Crotone, University of Calabria, Cosenza, Italy
| | - Francesco Riganello
- S. Anna Institute and Research in Advanced Neurorehabilitation (RAN), Crotone, University of Calabria, Cosenza, Italy
| | - Walter G. Sannita
- Department of Neuroscience, Ophthalmology and Genetics, University of Genova, Genova, Italy
- Department of Psychiatry, State University of New York, Stony Brook, New York
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Lancioni GE, O'Reilly MF, Singh NN, Sigafoos J, Buonocunto F, Sacco V, Colonna F, Navarro J, Lanzilotti C, de Pace C, Megna M, Oliva D. Communication opportunities via special messaging technology for two post-coma persons with multiple disabilities. RESEARCH IN DEVELOPMENTAL DISABILITIES 2011; 32:1703-1708. [PMID: 21440412 DOI: 10.1016/j.ridd.2011.02.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Accepted: 02/23/2011] [Indexed: 05/30/2023]
Abstract
This study extended the assessment of a special messaging technology with two additional post-coma adults who had emerged from a minimally conscious state, but showed multiple disabilities including profound motor and communication impairments. For each participant, the study involved an ABAB design, in which the A represented baseline phases and the B represented intervention phases with the special messaging technology. The technology involved a net-book computer provided with specific software, a global system for mobile communication (GSM) modem, microswitches, and prerecorded verbal lists of persons' names and messages. Both participants learned to send out and receive (listen to) messages independently during the intervention, thus providing clear support for previous data in the area. They sent out means of about three and 17 messages and received means of about two and six messages per 20- and 30-min session, respectively. The positive impact of the technology was discussed in relation to previous data in this area and the possibility of helping post-coma persons with multiple disabilities engage in basic communication with distant partners.
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Lancioni GE, O'Reilly MF, Singh NN, Oliva D, Buonocunto F, Belardinelli MO. Technology-assisted writing opportunities for a man emerged from a minimally conscious state and affected by extensive motor disabilities. Dev Neurorehabil 2011; 14:123-7. [PMID: 21410404 DOI: 10.3109/17518423.2010.549097] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To assess a computer-aided technology for assisting writing in a man who emerged from a minimally conscious state and presented with extensive motor disabilities. METHOD The technology served to present letters, in groups, at the centre of a computer screen and display (write) the letters selected by the man (i.e. through a simplified pointing response) on the upper half of that screen. RESULTS The results showed that the technology enabled the man to produce clear (readily readable) writing. This writing compared positively with the results obtained using a communication board containing the letters (i.e. a system already available to the man). CONCLUSION Computer-aided technology may provide basic writing (communication) opportunities to persons emerged from a minimally conscious state and affected by extensive motor disabilities and lack of speech.
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Lancioni G, O'Reilly M, Singh N, Buonocunto F, Sacco V, Colonna F, Navarro J, Oliva D, Megna M. Technology-assisted messaging opportunities for two persons emerged from a minimally conscious state and showing extensive motor disabilities. Dev Neurorehabil 2011; 14:8-14. [PMID: 21034286 DOI: 10.3109/17518423.2010.519760] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To extend the assessment of a special messaging technology with two adults emerged from a minimally conscious state and showing extensive motor disabilities as well as limited or no oral/verbal skills. METHOD The study involved a non-concurrent multiple baseline design across participants. Both participants started with baseline in which the technology was not available, and continued with intervention in which the technology was used. The technology involved a net-book computer provided with specific software, a global system for mobile communication (GSM) modem, microswitches, and pre-recorded lists of persons and messages. RESULTS Both participants learned to send out and receive (listen to) messages independently during the intervention. They sent out a mean of three or three and a half messages and received a mean of one and a half messages per 20-minute session. CONCLUSIONS Special messaging technology may help post-coma persons with multiple disabilities engage in basic communication with distant partners.
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Lancioni GE, Singh NN, O'reilly MF, Sigafoos J, De Pace C, Chiapparino C, Ricci I, Navarro J, Addante LM, Spica A. Technology-assisted programmes to promote leisure engagement in persons with acquired brain injury and profound multiple disabilities: two case studies. Disabil Rehabil Assist Technol 2011; 6:412-9. [DOI: 10.3109/17483107.2011.580899] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Dolce G, Lucca LF, Candelieri A, Rogano S, Pignolo L, Sannita WG. Visual pursuit in the severe disorder of consciousness. J Neurotrauma 2011; 28:1149-54. [PMID: 21175278 DOI: 10.1089/neu.2010.1405] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Visual pursuit is a key descriptor of the minimally conscious state (above 80% of cases). It is also observable in about 20% of subjects in vegetative state. Its reappearance after severe brain damage anticipates a favorable outcome, with recovery of consciousness in 73% of subjects (45% in the absence of it). We considered retrospectively 395 subjects in vegetative state because of traumatic (63%), massive acute vascular (30%), or diffuse anoxic-hypoxic (7%) brain damage consecutively admitted to one dedicated unit during the years 1998-2008. Visual tracking was observed in 290 subjects (73.4%) and was already detectable within 50 days from brain injury in about 60% of post-traumatic or vascular subjects and 21% of anoxic-hypoxic patients. After 230 days of follow-up or more, it was observed in 89% and 88% of post-traumatic and vascular subjects and in 67% of anoxic-hypoxic patients. Rating with the Glasgow Outcome Scale (GOS) was better in those subjects with recovered visual tracking and inversely correlated with the time of reappearance in post-traumatic and vascular subjects; also the subjects with late recovery of eye tracking (230 days or more) had better GOS outcome than those without it. The observation of visual tracking reappearing in subjects in vegetative state would reflect recuperation of the brainstem-cortical interaction and overall brain functional organization that are thought to sustain consciousness and are interfered with by the "functional disconnection," resulting in the vegetative state.
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Affiliation(s)
- Giuliano Dolce
- S. Anna Institute and Research in Advanced Neurorehabilitation, Via Siris 11, Crotone, Italy.
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Seel RT, Sherer M, Whyte J, Katz DI, Giacino JT, Rosenbaum AM, Hammond FM, Kalmar K, Pape TLB, Zafonte R, Biester RC, Kaelin D, Kean J, Zasler N. Assessment Scales for Disorders of Consciousness: Evidence-Based Recommendations for Clinical Practice and Research. Arch Phys Med Rehabil 2010; 91:1795-813. [PMID: 21112421 DOI: 10.1016/j.apmr.2010.07.218] [Citation(s) in RCA: 406] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2010] [Revised: 07/16/2010] [Accepted: 07/19/2010] [Indexed: 10/18/2022]
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Reliability and Diagnostic Characteristics of the JFK Coma Recovery Scale–Revised. J Head Trauma Rehabil 2010; 25:349-56. [DOI: 10.1097/htr.0b013e3181cec841] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Fins JJ. The ethics of measuring and modulating consciousness: the imperative of minding time. PROGRESS IN BRAIN RESEARCH 2010; 177:371-82. [PMID: 19818915 DOI: 10.1016/s0079-6123(09)17726-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Using time as an over-arching metaphor, and drawing upon resources in the sciences, humanities, and the history of medicine, the author addresses the neuroethics of measuring and modulating consciousness. Static and evolving views of time dating to the Ancients are contrasted and applied to severe brain injury. These temporal worldviews are tracked progressively in the philosophies of Democritus and Heraclitus, Hippocrates and Galen, and the neurosurgeon, Wilder Penfield on into the modern era as they relate to current perceptions related to disorders of consciousness. These disorders, typified by the vegetative and minimally conscious states, can be viewed as either fixed and immutable or in flux depending upon social currents and scientific knowledge. Variable perspectives are examined in light of right-to-die cases involving permanently vegetative patients like Quinlan and Schiavo and contrasting "late" recoveries involving patients in the minimally conscious state. The author suggests that disorders of consciousness should not be viewed categorically as static entities but rather assessed as a reflection of a synchrony of time and biology that we are just beginning to understand. He stresses the relationship of temporality to clinical evaluation, diagnosis assessment, and prognostication and their association to new methods in functional neuroimaging. These time stamps have profound implications for systems of care and reimbursement mechanisms, which often mistakenly conflates futility with chronicity. This conflation is increasingly being challenged by patients who emerge from the minimally conscious state after conventional temporal expectations for improvement had transpired. These cases often referred to as "late emergences" point to the importance of better understanding the natural history of these conditions and the tempo of associated recoveries.
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Affiliation(s)
- Joseph J Fins
- Division of Medical Ethics, Weill Medical College of Cornell University, New York, NY, USA.
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Wilson FC, Elder V, McCrudden E, Caldwell S. Analysis of Wessex Head Injury Matrix (WHIM) scores in consecutive vegetative and minimally conscious state patients. Neuropsychol Rehabil 2009; 19:754-60. [PMID: 19378215 DOI: 10.1080/09602010902805318] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Pistoia F, Sacco S, Palmirotta R, Onorati P, Carolei A, Sarà M. Mismatch of neurophysiological findings in partial recovery of consciousness: a case report. Brain Inj 2009; 22:633-7. [PMID: 18568718 DOI: 10.1080/02699050802189693] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Overgaard M. How can we know if patients in coma, vegetative state or minimally conscious state are conscious? PROGRESS IN BRAIN RESEARCH 2009; 177:11-9. [PMID: 19818891 DOI: 10.1016/s0079-6123(09)17702-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
This paper examines the claim that patients in coma, vegetative state and minimally conscious state may in fact be conscious. The topic is of great importance for a number of reasons--not least ethical. As soon as we know a given creature has any experiences at all, our ethical attitude towards it changes completely. A number of recent experiments looking for signs of intact or partially intact cognitive processing in the various stages of decreased level of consciousness are reviewed. Whether or not vegetative or coma patients are in fact conscious is an empirical issue that we yet do not know how to resolve. However, the simple fact that this is an unresolved empirical issue implies that the standard behavioural assessment is not sufficient to decide what it is like to be these patients. In other words, different and more sophisticated methods are necessary. From a theoretical position, the paper moves on to discuss differences in validity between reports (e.g. verbal) and signals (e.g. brain activations) in the study of consciousness, and whether results from experiments on the contents of consciousness may be of any use in the study of levels of consciousness. Finally, an integrated approach is suggested, which does not separate research in level and content as clearly as in current practice, and which may show a path to improved paradigms to determine whether patients in coma or vegetative state are conscious.
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Affiliation(s)
- Morten Overgaard
- CNRU, Hammel Neurorehabilitation and Research Unit, Aarhus University Hospital, Hammel, Denmark.
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Katz DI, Polyak M, Coughlan D, Nichols M, Roche A. Natural history of recovery from brain injury after prolonged disorders of consciousness: outcome of patients admitted to inpatient rehabilitation with 1-4 year follow-up. PROGRESS IN BRAIN RESEARCH 2009; 177:73-88. [PMID: 19818896 DOI: 10.1016/s0079-6123(09)17707-5] [Citation(s) in RCA: 194] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
UNLABELLED The natural history of recovery from brain injury typically consists of a period of impaired consciousness, a subsequent period of confusion and amnesia, followed by a period of post-confusional recovery of function. Patients with more severe injuries may have more prolonged episodes of unconsciousness or minimal consciousness and may not fully evolve through this continuum of recovery. There is limited information on the course of recovery and long-term outcome of patients with prolonged unconsciousness, particularly those with extended periods in the minimally conscious state. Further, patients with impaired consciousness are frequently denied access to hospital-based rehabilitation services because of uncertain prognosis and a perceived lack of benefit from rehabilitative interventions. METHODS A consecutive series of 36 patients with traumatic (TBI) and non-traumatic brain injury (nonTBI) in a vegetative state (VS) or minimally conscious state (MCS) on admission to a specialized, slow-to-recover brain injury program in an acute rehabilitation hospital was retrospectively reviewed to evaluate course of recovery during rehabilitation hospitalization and in follow-up, 1-4 years post-injury. Independent variables included: time to resolution of VS, MCS and confusional state/posttraumatic amnesia (CS/PTA), based on Aspen criteria, Coma Recovery Scale-Revised (CRS-R) and Galveston Orientation and Amnesia Test (GOAT) scores. Outcome measures (calculated separately for TBI, nonTBI, VS, or MCS on admission subgroups) included: proportion of patients who recover and recovery time to MCS, CS/PTA stages, household independence, and return to school or work, as well as Disability Rating Scale (DRS) scores at 1, 2, 3, and 4 years post-injury. RESULTS The majority emerged from MCS (72%) and CS/PTA (58%) by latest follow-up. It took significantly longer for patients admitted in VS (means: MCS, 16.43 weeks; CS/PTA, 30.1 weeks) than MCS (means: MCS, 7.36 weeks; CS/PTA, 11.5 weeks) to reach both milestones. Almost all who failed to clear CS/PTA by latest follow-up were patients with nonTBI or TBI with VS lasting over 8 weeks. Duration of MCS was a strong predictor of duration CS/PTA after emergence from MCS, accounting for 57% of the variance. Nearly half the patients followed at least 1 year achieved recovery to, at least, daytime independence at home and 22% returned to work or school, 17% at or near pre-injury levels. Discharge FIM score or duration of MCS, along with age, were best predictors of DRS in outcome models. DRS scores continued to improve after 2 and 3 years post-injury. CONCLUSIONS Patients in VS whose transition to MCS occurred within 8 weeks of onset are likely to continue recovering to higher levels of functioning, a substantial proportion to household independence, and productive pursuits. Patients with TBI are more likely to progress than patients with nonTBI, though significant improvement in the nonTBI group is still possible. Active, higher intensity, rehabilitation should be strongly considered for patients with severely impaired consciousness after brain injury, especially for patients with TBI who have signs of progression to the MCS.
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Affiliation(s)
- Douglas I Katz
- Department of Neurology, Boston University School of Medicine, Boston, MA, USA.
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Giacino JT, Smart CM. Recent advances in behavioral assessment of individuals with disorders of consciousness. Curr Opin Neurol 2008; 20:614-9. [PMID: 17992078 DOI: 10.1097/wco.0b013e3282f189ef] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The burden of proof for establishing diagnosis and prognosis in patients with disorders of consciousness lies with behavioral assessment methods. The current review discusses recent advances in understanding the strengths and weaknesses of this methodology. RECENT FINDINGS Behavioral assessment methods remain the 'gold standard' for establishing diagnosis and prognosis in patients with disorders of consciousness, although their psychometric integrity and clinical utility remain largely unproven. While the Glasgow Coma Scale maintains its standing in the trauma setting, there are ongoing concerns regarding testing confounds and interrater reliability. The Full Outline of UnResponsiveness, an emerging alternative, is more sensitive to detection of locked-in syndrome but may fail to identify patients in the minimally conscious state. Recent studies investigating the relationship between behavioral and neurophysiologic measures of conscious awareness have revealed important dissociations between behavioral response profiles and corresponding neural activity. SUMMARY Further research is needed on the psychometric properties of existing behavioral assessment methods for disorders of consciousness. Although dissociations between behavioral and neurophysiologic findings caution against overreliance on behavioral metrics for detection of conscious awareness, we expect there will be increased effort toward combining these methodologies to increase diagnostic accuracy and prognostic specificity in patients with disorders of consciousness.
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