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Bodien YG, LaRovere K, Kondziella D, Taran S, Estrano A, Shutter L. Common Data Elements for Disorders of Consciousness: Recommendations from the Working Group on Outcomes and Endpoints. Neurocrit Care 2024:10.1007/s12028-024-02068-1. [PMID: 39143375 DOI: 10.1007/s12028-024-02068-1] [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: 06/06/2024] [Accepted: 07/08/2024] [Indexed: 08/16/2024]
Abstract
BACKGROUND Clinical management of persons with disorders of consciousness (DoC) is dedicated largely to optimizing recovery. However, selecting a measure to evaluate the extent of recovery is challenging because few measures are designed to precisely assess the full range of potential outcomes, from prolonged DoC to return of preinjury functioning. Measures that are designed specifically to assess persons with DoC are often performance-based and only validated for in-person use. Moreover, there are no published recommendations addressing which outcome measures should be used to evaluate DoC recovery. The resulting inconsistency in the measures selected by individual investigators to assess outcome prevents comparison of results across DoC studies. The National Institute of Neurological Disorders and Stroke (NINDS) common data elements (CDEs) is an amalgamation of standardized variables and tools that are recommended for use in studies of neurologic diseases and injuries. The Neurocritical Care Society Curing Coma Campaign launched an initiative to develop CDEs specifically for DoC and invited our group to recommend CDE outcomes and endpoints for persons with DoCs. METHODS The Curing Coma Campaign Outcomes and Endpoints CDE Workgroup, consisting of experts in adult and pediatric neurocritical care, neurology, and neuroscience, used a previously established five-step process to identify and select candidate CDEs: (1) review of existing NINDS CDEs, (2) nomination and systematic vetting of new CDEs, (3) CDE classification, (4) iterative review and approval of panel recommendations, and (5) development of case report forms. RESULTS Among hundreds of existing NINDS outcome and endpoint CDE measures, we identified 20 for adults and 18 for children that can be used to assess the full range of recovery from coma. We also proposed 14 new outcome and endpoint CDE measures for adults and 5 for children. CONCLUSIONS The DoC outcome and endpoint CDEs are a starting point in the broader effort to standardize outcome evaluation of persons with DoC. The ultimate goal is to harmonize DoC studies and allow for more precise assessment of outcomes after severe brain injury or illness. An iterative approach is required to modify and adjust these outcome and endpoint CDEs as new evidence emerges.
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Affiliation(s)
- Yelena G Bodien
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, MA, USA.
| | - Kerri LaRovere
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel Kondziella
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Shaurya Taran
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Anna Estrano
- Department of Neurorehabilitation, IRCCS, Don Carlo Gnocchi Foundation, Florence, Italy
| | - Lori Shutter
- Departments of Critical Care Medicine, Neurology, and Neurosurgery, UPMC Healthcare System, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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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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Li H, Zhang X, Sun X, Dong L, Lu H, Yue S, Zhang H. Functional networks in prolonged disorders of consciousness. Front Neurosci 2023; 17:1113695. [PMID: 36875660 PMCID: PMC9981972 DOI: 10.3389/fnins.2023.1113695] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 01/25/2023] [Indexed: 02/19/2023] Open
Abstract
Prolonged disorders of consciousness (DoC) are characterized by extended disruptions of brain activities that sustain wakefulness and awareness and are caused by various etiologies. During the past decades, neuroimaging has been a practical method of investigation in basic and clinical research to identify how brain properties interact in different levels of consciousness. Resting-state functional connectivity within and between canonical cortical networks correlates with consciousness by a calculation of the associated temporal blood oxygen level-dependent (BOLD) signal process during functional MRI (fMRI) and reveals the brain function of patients with prolonged DoC. There are certain brain networks including the default mode, dorsal attention, executive control, salience, auditory, visual, and sensorimotor networks that have been reported to be altered in low-level states of consciousness under either pathological or physiological states. Analysis of brain network connections based on functional imaging contributes to more accurate judgments of consciousness level and prognosis at the brain level. In this review, neurobehavioral evaluation of prolonged DoC and the functional connectivity within brain networks based on resting-state fMRI were reviewed to provide reference values for clinical diagnosis and prognostic evaluation.
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Affiliation(s)
- Hui Li
- Rehabilitation Center, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.,Department of Neurorehabilitation, China Rehabilitation Research Center, Beijing, China.,University of Health and Rehabilitation Sciences, Qingdao, Shandong, China
| | - Xiaonian Zhang
- Department of Neurorehabilitation, China Rehabilitation Research Center, Beijing, China
| | - Xinting Sun
- Department of Neurorehabilitation, China Rehabilitation Research Center, Beijing, China
| | - Linghui Dong
- Rehabilitation Center, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.,Department of Neurorehabilitation, China Rehabilitation Research Center, Beijing, China.,University of Health and Rehabilitation Sciences, Qingdao, Shandong, China
| | - Haitao Lu
- Department of Neurorehabilitation, China Rehabilitation Research Center, Beijing, China
| | - Shouwei Yue
- Rehabilitation Center, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.,University of Health and Rehabilitation Sciences, Qingdao, Shandong, China
| | - Hao Zhang
- Rehabilitation Center, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.,Department of Neurorehabilitation, China Rehabilitation Research Center, Beijing, China.,University of Health and Rehabilitation Sciences, Qingdao, Shandong, China
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Changes of Spasticity across Time in Prolonged Disorders of Consciousness: A Retrospective Study. Brain Sci 2022; 12:brainsci12020295. [PMID: 35204057 PMCID: PMC8870216 DOI: 10.3390/brainsci12020295] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES In this retrospective study, we investigated how spasticity developed in patients diagnosed with a prolonged DOC over an almost two-year observation period (21 months), and how it related to the patients' age, gender, time since injury, etiology, level of consciousness, and anti-spastic medications. METHODS In total, 19 patients with a severe brain injury and prolonged DOC admitted to a long-term care facility were included in this study (14 male, age: 45.8 ± 15.3 years, 10 traumatic brain injury, 1.01 ± 0.99 years after brain injury, 11 minimally conscious state vs. 8 vegetative state). Each patient was assessed at admission and then quarterly, totaling eight assessments over 21 months. Spasticity was measured with the Modified Ashworth Scale (MAS) for both upper and lower limbs. The Western Neuro Sensory Stimulation Profile (WNSSP) was administered to assess the level of consciousness. Any other medical and demographic information of interest was obtained through medical records. Linear mixed models were used to assess each variable's impact on the change of spasticity over time. RESULTS Significant differences were observed in the evolution of spasticity in patients based on their etiology for the upper limbs [F (7, 107.29) = 2.226; p = 0.038], and on their level of consciousness for the lower limbs [F (7, 107.07) = 3.196; p = 0.004]. CONCLUSION Our preliminary results suggest that spasticity evolves differently according to the type of brain lesion and the level of consciousness. Spasticity in DOCs might therefore be mediated by different mechanisms and might have to be treated differently among patients. Future longitudinal studies should be performed prospectively in a bigger cohort and with data collection beginning earlier after brain injury to confirm our results and better understand the evolution of spasticity in this population.
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Fitzpatrick-DeSalme E, Long A, Patel F, Whyte J. Behavioral Assessment of Patients With Disorders of Consciousness. J Clin Neurophysiol 2022; 39:4-11. [PMID: 34474426 DOI: 10.1097/wnp.0000000000000666] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SUMMARY Brain injury resulting in coma may evolve into a prolonged disorder of consciousness, including the vegetative and minimally conscious states. Early detection of emerging consciousness has positive prognostic significance, and improvement in consciousness at any point may indicate the potential for meaningful communication and environmental control. Despite the importance of accurate assessment of consciousness, research indicates that as many as 40% of patients with a disorder of consciousness may be assessed incorrectly. Assessment of consciousness is challenging for many reasons, including the fact that consciousness cannot be measured directly but must be inferred from patterns of behavioral activity, that many patients have confounding deficits and treatments that may mask consciousness, and that patient performance may be highly variable over time. In this manuscript, we discuss strategies for optimizing patient status during assessment and review a number of structured assessment approaches that can be used. The available assessment techniques vary in their length and cost, and the expertise required to use them. Which of these approaches is most applicable to a given acute or subacute setting will vary with the volume of patients with a disorder of consciousness and the available resources. Importantly, lack of consciousness in the acute setting should not be used to justify the withdrawal of care or denial of rehabilitation services.
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Affiliation(s)
| | - Angela Long
- MossRehab, Albert Einstein Healthcare Network, Elkins Park, Pennsylvania, U.S.A.; and
| | - Ferzeen Patel
- MossRehab, Albert Einstein Healthcare Network, Elkins Park, Pennsylvania, U.S.A.; and
| | - John Whyte
- MossRehab, Albert Einstein Healthcare Network, Elkins Park, Pennsylvania, U.S.A.; and
- Moss Rehabilitation Research Institute, Elkins Park, Pennsylvania, U.S.A
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Murphy L. The Cognitive Assessment by Visual Election (CAVE): A pilot study to develop a cognitive assessment tool for people emerging from disorders of consciousness. Neuropsychol Rehabil 2018; 28:1275-1284. [DOI: 10.1080/09602011.2018.1454327] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Lesley Murphy
- Department for Neuro and Clinical Health Psychology, St George’s University Hospital Foundation Trust, London, UK
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Span-Sluyter CAMFH, Lavrijsen JCM, van Leeuwen E, Koopmans RTCM. Moral dilemmas and conflicts concerning patients in a vegetative state/unresponsive wakefulness syndrome: shared or non-shared decision making? A qualitative study of the professional perspective in two moral case deliberations. BMC Med Ethics 2018; 19:10. [PMID: 29471814 PMCID: PMC5824545 DOI: 10.1186/s12910-018-0247-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 01/29/2018] [Indexed: 11/10/2022] Open
Abstract
Background Patients in a vegetative state/ unresponsive wakefulness syndrome (VS/UWS) pose ethical dilemmas to those involved. Many conflicts occur between professionals and families of these patients. In the Netherlands physicians are supposed to withdraw life sustaining treatment once recovery is not to be expected. Yet these patients have shown to survive sometimes for decades. The role of the families is thought to be important. The aim of this study was to make an inventory of the professional perspective on conflicts in long-term care of patients in VS/UWS. Methods A qualitative study of transcripts on 2 Moral Deliberations (MD’s) in 2 cases of patients in VS/UWS in long-term care facilities. Results Six themes emerged: 1) Vision on VS/UWS; 2) Treatment and care plan; 3) Impact on relationships; 4) Feelings/attitude; 5) Communication; 6) Organizational aspects. These themes are related to professionals and to what families had expressed to the professionals. We found conflicts as well as contradictory feelings and thoughts to be a general feature in 4 of these themes, both in professionals and families. Conflicts were found in several actors: within families concerning all 6 themes, in nurse teams concerning the theme treatment and care plan, and between physicians concerning all 6 themes. Conclusions Different visions, different expectations and hope on recovery, deviating goals and contradictory feelings/thoughts in families and professionals can lead to conflicts over a patient with VS/UWS. Key factors to prevent or solve such conflicts are a carefully established diagnosis, clarity upon visions, uniformity in treatment goals and plans, an open and empathic communication, expertise and understanding the importance of contradictory feelings/thoughts. Management should bridge conflicts and support their staff, by developing expertise, by creating stability and by facilitating medical ethical discourses. Shared compassion for the patient might be a key to gain trust and bridge the differences from non-shared to shared decision making.
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Affiliation(s)
- Conny A M F H Span-Sluyter
- Radboud University Medical Centre, department of primary care, Nijmegen, The Netherlands. .,Novicare, Professionals in Elderly Care, Best, the Netherlands.
| | - Jan C M Lavrijsen
- Radboud University Medical Centre, department of primary care, Nijmegen, The Netherlands
| | | | - Raymond T C M Koopmans
- Radboud University Medical Centre, department of primary care, Nijmegen, The Netherlands.,Joachim en Anna, Centre for Specialized Geriatric Care, Nijmegen, The Netherlands
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