Analysis of Wessex Head Injury Matrix (WHIM) scores in consecutive vegetative and minimally conscious state patients

Syndrome of the Trephined and ParoxySmal Sympathetic Hyperactivity in a 17-year-old minimally conscious state patient: A Case Report

Purpose: Syndrome of the Trephined (SoT) is one of the most unknown complications of the Decompressive Craniectomy (DC) after Traumatic Brain Injury (TBI). A combination of neurological clinical criteria and radiological signs after DC is necessary to make its diagnosis. In our case, as the patient was in a minimally conscious state (MCS), it was impossible to clinically assess any neurological deterioration according to the criteria found in the literature. There is no description of clinical diagnostic criteria suitable for patients with MCS apart from the visible 'Skin Flap.'Method: A 17-year-old patient sustained a severe TBI. Two months after the TBI and a DC he exhibited an MCS with a Glasgow Coma Scale (GCS) of 7 and a Wessex Head Injury Matrix (WHIM) of 5. He presented several paroxysmal sympathetic hyperactivity (PSH) episodes a day and developed a sinking skin flap. A cranioplasty was performed. Then, we noticed the gradual disappearance of PSH episodes plus an improvement of the CRS and the WHIM. Results: The evolution of the WHIM data revealed a statistically significant difference (p 0.0047). Conclusion: Further studies should be conducted to assess whether the WHIM and the frequency of PSH episodes may be part of the diagnostic criteria for SoT in MCS patients.

Translation and Transcultural Adaptation of the Wessex Head Injury Matrix, Italian Version: A Preliminary Report

Background: Patients who are in a coma, a vegetative state or a minimally conscious state present a clinical challenge for neurological assessment, which is a prerequisite for establishing a prognosis and planning management. Several scales have been developed to evaluate these patients. The Wessex Head Injury Matrix is a comprehensive tool but is currently available only in the French and English languages. The aim of this study was to translate and evaluate the reliability of the Italian version of the scale. Methods: The original scale was translated according to a standard protocol: three separate translations were made, and a selected version was back-translated to check for any errors in order to obtain the most accurate Italian translation. A final back translation of the agreed version was made as a further check. The final version was then administered blind to a consecutive series of patients with severe acquired brain injury by two examiners. Inter-rater and test-retest reliability were assessed using a weighted Cohen’s kappa (Kw). Concurrent validity of the WHIM was evaluated by ρ Spearman’s correlation coefficient using the Glasgow Coma Scale (GCS) and the Coma Recovery Scale Revised (CRS-R) as the available gold standard. Results: Twenty-four patients (12 males and 12 females; mean age 59.9 ± 20.1; mean duration from index event 17.7 ± 20.0 days) with stroke (n = 15), traumatic brain injury (n = 7) and anoxic encephalopathy (n = 2) were included. Inter-rater [Kw 0.80 (95% CI 0.75–0.84)] and test-retest reliability [Kw 0.77 (95% CI 0.72–0.81)] showed good values. WHIM total scores correlated significantly with total scores on the GCS (ρ = 0.776; p < 0.001) and the CRS-R (ρ = 0.881; p < 0.001) demonstrating concurrent validity; Conclusion: The Italian version of the scale is now available for clinical practice and research.

The Use of Neuroscience and Psychological Measurement in England's Court of Protection

The 2005 Mental Capacity Act of England and Wales provides a description in statute law of a test determining if a person lacks "mental capacity" to take a particular decision and describes how the "best interests" of such a person should be determined. The Act established a new Court of Protection (CoP) to hear cases related to the Act and to rule on disputes over mental capacity. The court gathers a range of evidence, including reports from clinicians and experts. Human rights organisations and others have raised concerns about the nature of assessments for incapacity, including the role of brain investigations and psychometric tests. Aim: Describe use and interpretation of structured measures of psychological and brain function in CoP cases, to facilitate standardisation and improvement of practices, both in the courtroom and in non-legal settings. Method: Quantitative review of case law using all CoP judgments published until 2019. The judgments (n = 408) were read to generate a subset referring to structured testing (n = 50). These were then examined in detail to extract the nature of the measurements, circumstances of their use and features of interpretation by the court. Results: The 408 judgments contained 146 references to structured measurement of psychological or brain function, spread over 50 cases. 120/146 (82.2%) referred to "impairment of mind or brain," with this being part of assessment for incapacity in 58/146 (39.7%). Measurement referred on 25/146 (17.1%) occasions to "functional decision-making abilities." Structured measures were used most commonly by psychiatrists and psychologists. Psychological measurements comprised 66.4% of measures. Neuroimaging and electrophysiology were presented for diagnostic purposes only. A small number of behavioural measures were used for people with disorders of consciousness. When assessing incapacity, IQ and the Mini-Mental-State Examination were the commonest measures. A standardised measure of mental capacity itself was employed just once. Judges rarely integrated measurements in their capacity determinations. Conclusion: Structured testing of brain and psychological function is used in limited ways in the Court of Protection. Whilst there are challenges in creating measures of capacity, we highlight an opportunity for the neuroscience community to improve objectivity in assessment, inside and outside the courtroom.

Sensory stimulation to improve arousal in comatose patients after traumatic brain injury: a systematic review of the literature

BACKGROUND

No standard rehabilitative treatment for coma arousal after traumatic brain injury (TBI) exists. Based on our clinical experience, we hypothesized that sensory stimulation (SS) is a promising protocol to improve outcomes in these patients.

METHODS

We performed a literature review on the progress of sensory stimulation to enhance coma arousal after traumatic brain injury. We searched the databases on Medline, Embase, and Cochrane to gain access to relevant publications using the key words "traumatic brain injury," "disorders of consciousness," "sensory stimulation," and "coma scale."

RESULTS

We included all original studies published in English with patients presenting severe disorders of consciousness due to traumatic brain injury who had received SS and whose behavioral/neural responses had been measured. We compared data on ten selected studies and analyzed the SS effects in comatose patient outcomes after TBI. Our review outlines the role of SS in patients with TBI and provides guidance for its implementation in the clinical practice.

CONCLUSIONS

The literature suggests the SS program improves coma arousal after TBI. However, high-quality clinical trials are needed to establish standard SS protocols.

Human Computer Interface for Tracking Eye Movements Improves Assessment and Diagnosis of Patients With Acquired Brain Injuries

One of the first clinical signs differentiating the minimally conscious state from the vegetative state is the presence of smooth pursuit eye movements occurring in direct response to moving salient stimuli. Glasgow Coma Scale (GCS) is one of the most commonly used diagnostic tools for acute phase assessment of the level of consciousness, together with a neurological examination. These classic measures are limited to qualitative neurological examination without more quantitative measures provided from e.g., tasks with tracking position of the gaze. Among this and other limitations, it is prone to a relatively high rate of misdiagnosis. Here, we developed an interface for gaze tracking to enhance the assessment of consciousness in 10 patients with acquired brain injuries. According to the acute phase GCS assessment, nine of them were considered unaware and below the minimally conscious state. Chronic neurological examination confirmed six of them below the minimally conscious state. Our new Human Computer Interface (HCI) revealed that six patients were conscious enough to complete at least one of the gaze tracking tasks. Among these six patients, one was originally diagnosed as remaining in a vegetative state and one in coma. The patient diagnosed as remaining in a chronic vegetative state scored six GCS points acutely. Following assessment with our HCI the patient was re-diagnosed with a possible locked-in syndrome. Our HCI method provides a new complementary tool for clinical assessment of patients suffering from disorders of consciousness.

Does a regular Wessex Head Injury Matrix assessment identify early signs of infections in people with Prolonged Disorders of Consciousness?

BACKGROUND & OBJECTIVE

Patients with brain injury are at high risk for infections. Although infection and cognitive deterioration are established for people with dementia, this has not been shown for patients with a prolonged disorder of consciousness (PDOC). This study determines whether regular Wessex Head Injury Matrix (WHIM) assessments can identify early signs of infections in patients with PDOC.

METHOD

Retrospective and prospective approaches were used to assess the WHIM scores of patients with a PDOC (N = 21 in the retrospective study and 22 in the prospective study).

RESULTS

The WHIM total scores decreased due to infections in 17 of the 21 cases of infection (p < 0.001) in the retrospective study and 15 (p = 0.001) of the 22 prospective cases of infection. Patients in a minimally conscious state (MCS) showed a bigger proportion of change between their baseline score and the scores taken in the pre-infection stage in both the retrospective and prospective studies when compared to patients in a vegetative state (VS).

CONCLUSION

The findings suggest the importance of serial WHIM assessments throughout the period of recovery, not only to measure cognitive changes but also to highlight underlying physical changes such as infections that will impact the response to rehabilitation and recovery.

Caregivers' lived experience in trying to read slight movements in a child with severe brain injury: A phenomenological study

AIMS AND OBJECTIVES

To explore caregivers' lived experience of reading slight movements of a child with severe brain injury.

BACKGROUND

Despite increased need, the development of individual care for children with severe brain injuries has been prevented by their severe physical state and the poor reproducibility of their movements. In addition to a lack of evidence on the motor characteristics of patients with severe brain injury with multiple disabilities, their own development contributes to increasing variability in their states. Thus, caregivers are compelled to rely on their experiences, which have not been academically explored.

DESIGN

A qualitative study based on van Manen's method of hermeneutic phenomenology.

METHODS

Data were obtained through twenty-one 3-hr observation sessions and five 15- to 45-min group interviews. We observed a child (called AK) with severe brain injury and his 61 caregivers, and conducted group interviews with 28 caregivers. We focused on caregivers' experiences of reading AK's slight movements. The data were interpreted based on van Manen's hermeneutic phenomenological approach.

RESULTS

Four themes emerged as caregivers' experience in trying to read AK's slight movements. By considering "AK's physical state and his slight movements" and discovering "caregivers' 'sense of uncertainty' about AK's slight movements," caregivers could decipher "AK's multiple slight movements." "Sharing" was found as a necessary aspect of these other three themes of reading AK's slight movements.

CONCLUSIONS

We presented caregivers' experiences as related to these four themes in their efforts to read the slight movements of AK. Due to AK's slight movements with poor reproducibility, "sharing" was necessary to read AK's slight movements, as it exposes caregivers' lived experience to the interpretation of multiple caregivers.

RELEVANCE TO CLINICAL PRACTICE

These four themes may be useful for assessing, guiding and promoting caregivers' use of sharing when reading the slight movements of children with severe brain injury.

Comparison of SMART and WHIM as measurement tools in routine assessment of PDOC patients

BACKGROUND

Royal College of Physicians guidelines on PDOC recommended repeated assessments of patients in PDOC are undertaken by skilled clinicians. The Wessex Head Injury Matrix (WHIM) and the Sensory Modality Assessment and Rehabilitation Technique (SMART) are the most commonly used measures within UK.

OBJECTIVE

To evaluate the use of WHIM and SMART to identify potential changes in PDOC patients.

METHODS

Twelve PDOC patients admitted to a post-acute regional neuro-rehabilitation unit were assessed using WHIM and SMART. Eight of 12 patients were diagnosed with a primary hypoxic ischemic brain injury (HIBI).

RESULTS

Overall for the total group there was no significant correlation between patient's highest ranked behaviour and any SMART domain. Initial WHIM total observed behaviour was significantly correlated with SMART tactile domain. Patient's final WHIM and SMART domains were not significantly correlated. Among HIBI subgroup, initial WHIM highest ranked behaviour and WHIM total observed behaviour were significantly correlated with the SMART communication domain. Final WHIM highest ranked behaviour was positively correlated with SMART visual and tactile domains. Final WHIM total observed behaviour was significantly correlated with the SMART visual domain.

CONCLUSIONS

Both measures show sensitivity to change in PDOC patients. Larger long-term follow-up of HIBI patients is highlighted.

Serial measurement of Wessex Head Injury Matrix in the diagnosis of patients in vegetative and minimally conscious states: a cohort analysis

OBJECTIVE

To evaluate serial application of the Wessex Head Injury Matrix (WHIM) in diagnosis of prolonged disorders of consciousness (PDOC). Specifically, to determine whether the trajectory of change predicts outcome status, and whether the current hierarchical order of WHIM items is correct for this context.

DESIGN

Analysis of prospectively gathered clinical cohort data.

SETTING

Consecutive admissions to a tertiary in-patient neurorehabilitation service for evaluation of PDOC in real-life clinical practice, over a 10-year period (2004-2014).

PARTICIPANTS

Patients (n=65) presenting in sudden-onset vegetative (VS) or minimally conscious states (MCS). Mean age 38.4 (sd14.1) years; male:female ratio 66%:33%. Aetiology of brain injury: 40(62%) traumatic; 12(19%) vascular; 11(17%) hypoxic; 3(3%) other.

PRIMARY OUTCOME MEASURE

WHIM alongside detailed clinical evaluation.

METHODS

The WHIM was administered serially by the multidisciplinary team throughout an in-patient evaluation programme (mean length 74 (sd42) days). Patients were divided into four groups, according to PDOC status on discharge (VS, MCS-Minus, MCS-Plus or Emerged).

RESULTS

WHIM hierarchical scores (Most Advanced Behaviour (MAB)) correlated with PDOC status at discharge (Pearson r=0.49, p<0.001). In the original order, the MAB distinguished the 'VS', 'MCS' and 'Emerged' categories (analysis of variance (ANOVA) post hoc p<0.001), but not the subgroups of MCS-Minus and MCS-Plus. In stepwise regression analysis, MAB-Ex (excluding two items) accounted for 68% of the variance in PDOC status at discharge. On multilevel statistical modelling, trajectory of change in MAB separated the four PDOC groups, both at individual and at group level (p<0.001). After reordering of items, the new-order MAB accounted for more (73%) of the variance in PDOC status, and also distinguished significantly between MCS-Minus and MCS-Plus groups at discharge (p<0.002).

CONCLUSIONS

The WHIM is a useful diagnostic tool in PDOC, and trajectory of change is an important predictor of outcome. The proposed new hierarchical order requires further evaluation in future multicentre analyses.

Influence of intrathecal baclofen on the level of consciousness and mental functions after extremely severe traumatic brain injury: brief report

BACKGROUND

Whenever oral treatment or botulinum toxin injections fail to control severe spasticity, a trial with intrathecal baclofen is recommended no earlier than 1 year after brain injury. When irreversible contractures are to be avoided, such a trial might be done earlier. Some have briefly reported cognitive modifications with this treatment.

METHODS

During the trial period, intrathecal baclofen is continuously infused by a portable external pump through an intrathecal catheter. The daily dose is adjusted according to the clinical response. If the expected response is obtained by reduction of spasticity, a programmable pump is then implanted. Throughout the procedure, close neuropsychological follow-up is pursued.

RESULTS

Two persons with extremely severe brain injury and spasticity received a programmable pump less than 10 months after trauma. Unexpectedly, one emerged from the minimally conscious state and the other from post-traumatic amnesia.

CONCLUSIONS

Intrathecal baclofen should be considered within the first year after brain injury whenever spasticity does not respond to medication. ITB lessens the degree of spasticity which in turn facilitates care and, thus, has the potential to limit contractures. After severe brain injury, this treatment might trigger recovery from altered states of consciousness, improve cognition and facilitate rehabilitation.

Responsiveness of Instruments to Assess Disorders of Consciousness: A Literature Review

Objectives: To summarise available evidence for responsiveness of six key assessments used with patients with disorders of consciousness: Coma Recovery Scale – Revised (CRS-R), Disorders Of Consciousness Scale (DOCS), Sensory Modality Assessment and Rehabilitation Technique (SMART), Sensory Stimulation Assessment Measure (SSAM), Wessex Head Injury Matrix (WHIM), and the Western Neuro Sensory Stimulation Profile (WNSSP).

Method: A literature search of five electronic databases was conducted using a systematic search strategy. Relevant literature was evaluated and pertinent information extracted.

Results: Database searches using key terms initially yielded 132 articles. Following review for inclusion identified 24 articles. No studies were specifically designed to investigate responsiveness of any of the measures and therefore responsiveness data were either based on statistical significance of change post-treatment or descriptive analysis of change scores. The majority of studies identified used the CRS-R (n= 11), WHIM (n= 5) and WNSSP (n= 6) and have established responsiveness to change. There is some preliminary evidence for the responsiveness of the other measures, based on very few available studies: DOCS (n= 2), SMART (n= 1) or SSAM (n= 1).

Conclusion: Future studies should seek to include responsiveness analysis, particularly in relation to the DOCS, SMART and SSAM.

Intensive physiotherapy for vegetative and minimally conscious state patients: a retrospective audit and analysis of therapy intervention

PURPOSE

To analyse physiotherapy interventions and evaluate their effectiveness in the prevention and management of contracture with patients admitted in either vegetative or minimally conscious state in a UK Inpatient Regional Acquired Brain Injury Rehabilitation Service.

METHOD

Retrospective audit of dependency levels and physiotherapy interventions in ten vegetative or minimally conscious state patients admitted over a 3-year period (2006-2009). Admission and discharge patient dependency status, Wessex Head Injury Matrix data and passive range of movement measurements on admission and discharge from physiotherapy were recorded.

RESULTS

All patients presented with hypertonicity including contractures and all initially received a manual stretching/passive movement programme. Casting/splinting was employed in 8 cases and 7 received botulinum toxin injections. Standing regimes were initiated for 8 patients. No patient emerged out of either vegetative or minimally conscious state. Although they remained fully dependent for care needs, carer burden was reduced and all patients were able sustain a seating regimen. No minimal clinically important difference was observed in 85 out of 120 joint ranges measured (70.8%). Positive outcomes were observed in only 14 joints (11.7%) and negative outcomes in 21 joints (17.5%).

CONCLUSION

At present, there is a paucity of evidence regarding physiotherapy efficacy to inform the management of patients in vegetative or minimally conscious state. Clearer agreed definitions of clinically important difference in passive range of movement are required to allow better interpretation of outcomes. Interventions should be aimed at minimising carer burden and developing individualised disability management programmes. Further research documenting the long-term outcomes in such patients is warranted.