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Barra ME, Solt K, Yu X, Edlow BL. Restoring consciousness with pharmacologic therapy: Mechanisms, targets, and future directions. Neurotherapeutics 2024:e00374. [PMID: 39019729 DOI: 10.1016/j.neurot.2024.e00374] [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: 12/01/2023] [Revised: 04/16/2024] [Accepted: 05/03/2024] [Indexed: 07/19/2024] Open
Abstract
Severe brain injury impairs consciousness by disrupting a broad spectrum of neurotransmitter systems. Emerging evidence suggests that pharmacologic modulation of specific neurotransmitter systems, such as dopamine, promotes recovery of consciousness. Clinical guidelines now endorse the use of amantadine in individuals with traumatic disorders of consciousness (DoC) based on level 1 evidence, and multiple neurostimulants are used off-label in clinical practice, including methylphenidate, modafinil, bromocriptine, levodopa, and zolpidem. However, the relative contributions of monoaminergic, glutamatergic, cholinergic, GABAergic, and orexinergic neurotransmitter systems to recovery of consciousness after severe brain injury are unknown, and personalized approaches to targeted therapy have yet to be developed. This review summarizes the state-of-the-science in the neurochemistry and neurobiology of neurotransmitter systems involved in conscious behaviors, followed by a discussion of how pharmacologic therapies may be used to modulate these neurotransmitter systems and promote recovery of consciousness. We consider pharmacologic modulation of consciousness at the synapse, circuit, and network levels, with a focus on the mesocircuit model that has been proposed to explain the consciousness-promoting effects of various monoaminergic, glutamatergic, and paradoxically, GABAergic therapies. Though fundamental questions remain about neurotransmitter mechanisms, target engagement and optimal therapy selection for individual patients, we propose that pharmacologic therapies hold great promise to promote recovery and improve quality of life for patients with severe brain injuries.
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Affiliation(s)
- Megan E Barra
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA; Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, MA, USA
| | - Ken Solt
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Xin Yu
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, USA
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, MA, USA; Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, USA; Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
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2
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Tinti L, Lawson T, Molteni E, Kondziella D, Rass V, Sharshar T, Bodien YG, Giacino JT, Mayer SA, Amiri M, Muehlschlegel S, Venkatasubba Rao CP, Vespa PM, Menon DK, Citerio G, Helbok R, McNett M. Research considerations for prospective studies of patients with coma and disorders of consciousness. Brain Commun 2024; 6:fcae022. [PMID: 38344653 PMCID: PMC10853976 DOI: 10.1093/braincomms/fcae022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 01/04/2024] [Accepted: 01/26/2024] [Indexed: 03/02/2024] Open
Abstract
Disorders of consciousness are neurological conditions characterized by impaired arousal and awareness of self and environment. Behavioural responses are absent or are present but fluctuate. Disorders of consciousness are commonly encountered as a consequence of both acute and chronic brain injuries, yet reliable epidemiological estimates would require inclusive, operational definitions of the concept, as well as wider knowledge dissemination among involved professionals. Whereas several manifestations have been described, including coma, vegetative state/unresponsive wakefulness syndrome and minimally conscious state, a comprehensive neurobiological definition for disorders of consciousness is still lacking. The scientific literature is primarily observational, and studies-specific aetiologies lead to disorders of consciousness. Despite advances in these disease-related forms, there remains uncertainty about whether disorders of consciousness are a disease-agnostic unitary entity with a common mechanism, prognosis or treatment response paradigm. Our knowledge of disorders of consciousness has also been hampered by heterogeneity of study designs, variables, and outcomes, leading to results that are not comparable for evidence synthesis. The different backgrounds of professionals caring for patients with disorders of consciousness and the different goals at different stages of care could partly explain this variability. The Prospective Studies working group of the Neurocritical Care Society Curing Coma Campaign was established to create a platform for observational studies and future clinical trials on disorders of consciousness and coma across the continuum of care. In this narrative review, the author panel presents limitations of prior observational clinical research and outlines practical considerations for future investigations. A narrative review format was selected to ensure that the full breadth of study design considerations could be addressed and to facilitate a future consensus-based statement (e.g. via a modified Delphi) and series of recommendations. The panel convened weekly online meetings from October 2021 to December 2022. Research considerations addressed the nosographic status of disorders of consciousness, case ascertainment and verification, selection of dependent variables, choice of covariates and measurement and analysis of outcomes and covariates, aiming to promote more homogeneous designs and practices in future observational studies. The goal of this review is to inform a broad community of professionals with different backgrounds and clinical interests to address the methodological challenges imposed by the transition of care from acute to chronic stages and to streamline data gathering for patients with disorders of consciousness. A coordinated effort will be a key to allow reliable observational data synthesis and epidemiological estimates and ultimately inform condition-modifying clinical trials.
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Affiliation(s)
- Lorenzo Tinti
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan 20156, Italy
| | - Thomas Lawson
- Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Erika Molteni
- Biomedical Engineering Department, School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EU, UK
| | - Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen 2100, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen 2200, Denmark
| | - Verena Rass
- Department of Neurology, Neuro-Intensive Care Unit, Medical University of Innsbruck, Innsbruck 6020, Austria
| | - Tarek Sharshar
- Neuro-Intensive Care Medicine, Anaesthesiology and ICU Department, GHU-Psychiatry and Neurosciences, Pole Neuro, Sainte-Anne Hospital, Institute of Psychiatry and Neurosciences of Paris, INSERM U1266, Université Paris Cité, Paris 75006, France
| | - Yelena G Bodien
- Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, MA 02129, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, MA 02129, USA
| | - Stephan A Mayer
- Department of Neurology, New York Medical College, Valhalla, NY 10595, USA
- Department of Neurosurgery, New York Medical College, Valhalla, NY 10595, USA
| | - Moshgan Amiri
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen 2100, Denmark
| | - Susanne Muehlschlegel
- Department of Neurology and Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Chethan P Venkatasubba Rao
- Division of Vascular Neurology and Neurocritical Care, Baylor College of Medicine and CHI Baylor St Luke’s Medical Center, Houston, TX 77030, USA
| | - Paul M Vespa
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Cambridge CB2 1TN, UK
| | - Giuseppe Citerio
- NeuroIntensive Care, IRCSS Fondazione San Gerardo dei Tintori, Monza 20900, Italy
- School of Medicine and Surgery, Università Milano Bicocca, Milan 20854, Italy
| | - Raimund Helbok
- Department of Neurology, Neuro-Intensive Care Unit, Medical University of Innsbruck, Innsbruck 6020, Austria
- Department of Neurology, Johannes Kepler University, Linz 4040, Austria
| | - Molly McNett
- College of Nursing, The Ohio State University, Columbus, OH 43210, USA
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3
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Thibaut A, Aloisi M, Dreessen J, Alnagger N, Lejeune N, Formisano R. Neuro-orthopaedic assessment and management in patients with prolonged disorders of consciousness: A review. NeuroRehabilitation 2024; 54:75-90. [PMID: 38251069 DOI: 10.3233/nre-230137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
BACKGROUND Following a severe acquired brain injury, neuro-orthopaedic disorders are commonplace. While these disorders can impact patients' functional recovery and quality of life, little is known regarding the assessment, management and treatment of neuro-orthopaedic disorders in patients with disorders of consciousness (DoC). OBJECTIVE To describe neuro-orthopaedic disorders in the context of DoC and provide insights on their management and treatment. METHODS A review of the literature was conducted focusing on neuro-orthopaedic disorders in patients with prolonged DoC. RESULTS Few studies have investigated the prevalence of spastic paresis in patients with prolonged DoC, which is extremely high, as well as its correlation with pain. Pilot studies exploring the effects of pharmacological treatments and physical therapy show encouraging results yet have limited efficacy. Other neuro-orthopaedic disorders, such as heterotopic ossification, are still poorly investigated. CONCLUSION The literature of neuro-orthopaedic disorders in patients with prolonged DoC remains scarce, mainly focusing on spastic paresis. We recommend treating neuro-orthopaedic disorders in their early phases to prevent complications such as pain and improve patients' recovery. Additionally, this approach could enhance patients' ability to behaviourally demonstrate signs of consciousness, especially in the context of covert awareness.
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Affiliation(s)
- Aurore Thibaut
- Coma Science Group, GIGA-Consciousness, University of Liege, Liege, Belgium
- Centre du Cerveau, University Hospital of Liege, Liege, Belgium
| | - Marta Aloisi
- Post-Coma Unit and Neurorehabilitation, IRCCS Fondazione Santa Lucia, Rome, Italy
| | - Joëlle Dreessen
- Centre Hospitalier Neurologique William Lennox, Ottignies-Louvain-la-Neuve, Belgium
| | - Naji Alnagger
- Coma Science Group, GIGA-Consciousness, University of Liege, Liege, Belgium
- Centre du Cerveau, University Hospital of Liege, Liege, Belgium
| | - Nicolas Lejeune
- Coma Science Group, GIGA-Consciousness, University of Liege, Liege, Belgium
- Centre du Cerveau, University Hospital of Liege, Liege, Belgium
- Centre Hospitalier Neurologique William Lennox, Ottignies-Louvain-la-Neuve, Belgium
| | - Rita Formisano
- Post-Coma Unit and Neurorehabilitation, IRCCS Fondazione Santa Lucia, Rome, Italy
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Park JY, Park J, Baek J, Chang JW, Kim YG, Chang WS. Long-term results on the suppression of secondary brain injury by early administered low-dose baclofen in a traumatic brain injury mouse model. Sci Rep 2023; 13:18563. [PMID: 37903976 PMCID: PMC10616194 DOI: 10.1038/s41598-023-45600-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 10/21/2023] [Indexed: 11/01/2023] Open
Abstract
Secondary injury from traumatic brain injury (TBI) perpetuates cerebral damages through varied ways. Attenuating neuroinflammation, which is a key feature of TBI, is important for long-term prognosis of its patients. Baclofen, a muscle relaxant, has shown promise in reducing excessive inflammation in other neurologic disorders. However, its effectiveness in TBI remains ambiguous. Thus, our study aimed to investigate whether early administration of baclofen could elicit potential therapeutic effects by diminishing exaggerated neuroinflammation in TBI mice. In this study, 80 C57BL/6 mice were used, of which 69 mice received controlled cortical impact. The mice were divided into six groups (11-16 mice each). Baclofen, administered at dose of 0.05, 0.2 and 1 mg/kg, was injected intraperitoneally a day after TBI for 3 consecutive weeks. 3 weeks after completing the treatments, the mice were assessed histologically. The results showed that mice treated with baclofen exhibited a significantly lower volume of lesion tissue than TBI mice with normal saline. Baclofen also reduced activated glial cells with neurotoxic immune molecules and inhibited apoptotic cells. Significant recovery was observed and sustained for 6 weeks at the 0.2 mg/kg dose in the modified neurological severity score. Furthermore, memory impairment was recovered with low-doses of baclofen in the Y-maze. Our findings demonstrate that early administration of low dose baclofen can regulate neuroinflammation, prevent cell death, and improve TBI motor and cognitive abnormalities.
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Affiliation(s)
- Ji Young Park
- Department of Neurosurgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Junwon Park
- Department of Neurosurgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Jiwon Baek
- Department of Neurosurgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Jin Woo Chang
- Department of Neurosurgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
- Brain Korea 21 PLUS Project for Medical Science and Brain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Goo Kim
- Department of Neurosurgery, Ewha Womans University School of Medicine, Ewha Womans University Mokdong Hospital, Mok 5-dong, Yangcheon-gu, Seoul, 07985, Republic of Korea.
| | - Won Seok Chang
- Department of Neurosurgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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Luauté J, Beaudoin-Gobert M. Optimising recovery of consciousness after coma. From bench to bedside and vice versa. Presse Med 2023; 52:104165. [PMID: 36948412 DOI: 10.1016/j.lpm.2023.104165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/13/2023] [Indexed: 03/24/2023] Open
Abstract
BACKGROUND Several methods have been proposed to foster recovery of consciousness in patients with disorders of consciousness (DoC). OBJECTIVE Critically assess pharmacological and non-pharmacological treatments for patients with chronic DoC. METHODS A narrative mini-review, and critical analysis of the scientific literature on the various proposed therapeutic approaches, with particular attention to level of evidence, risk-benefit ratio, and feasibility. RESULTS AND DISCUSSION Personalised sensory stimulation, median nerve stimulation, transcranial direct current stimulation (tDCS), amantadine and zolpidem all have favourable risk-benefit ratios and are easy to implement in clinical practice. These treatments should be proposed to every patient with chronic DoC. Comprehensive patient management should also include regular lifting, pain assessment and treatment, attempts to restore sleep and circadian rhythms, implementation of rest periods, comfort and nursing care, and a rehabilitation program with a multi-disciplinary team with expertise in this field. More invasive treatments may cause adverse effects and require further investigation to confirm preliminary, encouraging results and to better define responders' intervention parameters. Scientific studies are essential and given the severity of the disability and handicap that results from DoC, research in this area should aim to develop new therapeutic approaches.
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Affiliation(s)
- Jacques Luauté
- Université Claude Bernard Lyon 1, CNRS, INSERM, Centre de Recherche en Neurosciences de Lyon CRNL U1028 UMR5292, Trajectoires, F-69500 Bron, France; Hôpital Henry Gabrielle, Saint-Genis Laval, Hospices Civils de Lyon, 69230 France.
| | - Maude Beaudoin-Gobert
- Université Claude Bernard Lyon 1, CNRS, INSERM, Centre de Recherche en Neurosciences de Lyon CRNL U1028 UMR5292, Trajectoires, F-69500 Bron, France
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Raciti L, Raciti G, Militi D, Tonin P, Quartarone A, Calabrò RS. Sleep in Disorders of Consciousness: A Brief Overview on a Still under Investigated Issue. Brain Sci 2023; 13:brainsci13020275. [PMID: 36831818 PMCID: PMC9954700 DOI: 10.3390/brainsci13020275] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/29/2023] [Accepted: 02/06/2023] [Indexed: 02/09/2023] Open
Abstract
Consciousness is a multifaceted concept, involving both wakefulness, i.e., a condition of being alert that is regulated by the brainstem, and awareness, a subjective experience of any thoughts or perception or emotion. Recently, the European Academy of Neurology has published international guidelines for a better diagnosis of coma and other disorders of consciousness (DOC) through the investigation of sleep patterns, such as slow-wave and REM, and the study of the EEG using machine learning methods and artificial intelligence. The management of sleep disorders in DOC patients is an increasingly hot topic and deserves careful diagnosis, to allow for the most accurate prognosis and the best medical treatment possible. The aim of this review was to investigate the anatomo-physiological basis of the sleep/wake cycle, as well as the main sleep patterns and sleep disorders in patients with DOC. We found that the sleep characteristics in DOC patients are still controversial. DOC patients often present a theta/delta pattern, while epileptiform activity, as well as other sleep elements, have been reported as correlating with outcomes in patients with coma and DOC. The absence of spindles, as well as REM and K-complexes of NREM sleep, have been used as poor predictors for early awakening in DOC patients, especially in UWS patients. Therefore, sleep could be considered a marker of DOC recovery, and effective treatments for sleep disorders may either indirectly or directly favor recovery of consciousness.
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Affiliation(s)
| | | | - David Militi
- IRCCS Centro Neurolesi Bonino Pulejo, 98121 Messina, Italy
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Min JH, Shin YI. Treatment and Rehabilitation for Traumatic Brain Injury: Current Update. BRAIN & NEUROREHABILITATION 2022; 15:e14. [PMID: 36743200 PMCID: PMC9833473 DOI: 10.12786/bn.2022.15.e14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/20/2022] [Accepted: 07/21/2022] [Indexed: 11/08/2022] Open
Abstract
Traumatic brain injury (TBI) is an acquired injury to the brain caused by external mechanical forces, which can cause temporary or permanent disability. TBI and its potential long-term consequences are serious public health concerns. This review seeks to provide updated information on the current methods of management of patients with TBI to improve patient care.
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Affiliation(s)
- Ji Hong Min
- Department of Rehabilitation Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Yong-Il Shin
- Department of Rehabilitation Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Rehabilitation Medicine, Pusan National University School of Medicine, Busan, Korea
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Barra ME, Edlow BL, Brophy GM. Pharmacologic Therapies to Promote Recovery of Consciousness. Semin Neurol 2022; 42:335-347. [PMID: 36100228 DOI: 10.1055/s-0042-1755271] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Pharmacologic interventions are commonly used to support rehabilitation efforts of patients with disorders of consciousness (DoC). The 2018 practice guidelines recommend amantadine in adults with traumatic DoC to promote functional recovery, though several other stimulants are used off-label in clinical practice and trials, such as methylphenidate, bromocriptine, levodopa, and zolpidem. Differences in the mechanisms of action, adverse effects, pharmacokinetics, and drug-drug interactions should be considered when selecting the best agent for each individual patient. Overall, pharmacologic stimulants may provide a safe and inexpensive pathway to increased functionality and participation in rehabilitation. This article provides a concise summary of scientific evidence supporting the use of pharmacologic therapies to stimulate recovery of consciousness in patients with DoC.
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Affiliation(s)
- Megan E Barra
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts.,Department of Neurology, Center for Neurotechnology and Neurorecovery (CNTR), Massachusetts General Hospital, Boston, Massachusetts
| | - Brian L Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery (CNTR), Massachusetts General Hospital, Boston, Massachusetts.,Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, Massachusetts
| | - Gretchen M Brophy
- Department of Pharmacotherapy and Outcomes Science and Neurosurgery, Virginia Commonwealth University, Medical College of Virginia, Richmond, Virginia
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Halbmayer LM, Kofler M, Hitzenberger G, Matzak H, Fava E, Genelin E, Werkmann M, Saltuari L, Versace V, Dobesberger J, Pucks-Faes E. On the recovery of disorders of consciousness under intrathecal baclofen administration for severe spasticity-An observational study. Brain Behav 2022; 12:e2566. [PMID: 35398998 PMCID: PMC9120732 DOI: 10.1002/brb3.2566] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 01/30/2022] [Accepted: 03/05/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Occasionally, patients show dramatic recovery from disorders of consciousness (DOC) under intrathecal baclofen (ITB), an established treatment option for severe supraspinal spasticity. Anecdotal explanations for ITB-related recovery of cognition include modulation of afferent impulses at the spinal level, thereby reducing spasticity-related proprioceptive information overload within cortico-thalamo-cortical connections. OBJECTIVE In this retrospective patient chart analysis, we assessed whether a reduction in spasticity would be associated with an increase in Coma Recovery Scale revised (CRS-R) scores in a larger sample of patients than previously published. METHODS From a hospital-based ITB treatment register, we extracted data from 26 patients with DOC and severe supraspinal spasticity who improved by >2 points on the Coma Recovery Scale revised (CRS-R) within 6 months after ITB treatment initiation. We assessed Modified Ashworth scale (MAS) scores and CRS-R scores on admission (PRE) and 3 and 6 months after initiation of ITB treatment (3M, 6M). We performed correlation analysis of the scores and their respective changes (PRE to 3M, 3M to 6M). We also correlated the time from acute event until ITB initiation to CRS-R scores at 3M and 6M. RESULTS ITB led to significant improvement in spasticity based on MAS scores, which did not correlate to the improvements seen in CRS-R total and subscale scores. Daily ITB dose did neither correlate to MAS scores nor to CRS-total scores in the whole patient group, but after 3 months, ITB dose correlated to some CRS-R subscale scores in some patient subgroups. Time until ITB treatment did not correlate to CRS-R scores later on. CONCLUSIONS Our data confirm that ITB may exert beneficial effects in selected DOC patients with respect to improved cognitive functions, which, however, do not correlate to its antispastic effect. The lack of correlation between time to ITB and CRS-R outcome, but significant CRS-R improvements following pump implantation, renders spontaneous remissions unlikely and leaves room for alternative pharmacological mechanisms.
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Affiliation(s)
| | - Markus Kofler
- Department of Neurology, Hochzirl Hospital, Zirl, Austria
| | | | | | - Elena Fava
- Department of Neurology, Hochzirl Hospital, Zirl, Austria
| | | | - Mario Werkmann
- Department of Neurology, Hochzirl Hospital, Zirl, Austria
| | - Leopold Saltuari
- Department of Neurorehabilitation, Hospital of Vipiteno (SABES-ASDAA), Vipiteno, Italy.,Research Unit for Neurorehabilitation, Bolzano, Italy
| | - Viviana Versace
- Department of Neurorehabilitation, Hospital of Vipiteno (SABES-ASDAA), Vipiteno, Italy
| | - Judith Dobesberger
- Rehabilitation Center Großgmain, Pensionsversicherungsanstalt, Teaching Hospital of Paracelsus Medical University, Salzburg, Austria
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Bonin EAC, Binda Fossati ML, Filippini MM, Bornheim S, Lejeune N, O'Brien AT, Bodart O, Laureys S, Thibaut A, Chatelle C. Evaluation of the effect of analgesic treatment on signs of nociception-related behaviors during physiotherapy in patients with disorders of consciousness: a pilot crossover randomized controlled trial. Pain 2022; 163:e349-e356. [PMID: 34393202 DOI: 10.1097/j.pain.0000000000002367] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 04/12/2021] [Indexed: 11/27/2022]
Abstract
ABSTRACT Neuro-orthopedic disorders are common in patients with disorders of consciousness (DOC) and can lead to potential pain. However, the patients' inability to communicate makes pain detection and management very challenging for clinicians. In this crossover randomized double-blind placebo-controlled study, we investigated the effects of an analgesic treatment on the presence of nociception-related behaviors. At baseline, the Nociception Coma Scale-Revised (NCS-R) was performed in 3 conditions: a non-noxious stimulation, a noxious stimulation, and during a physiotherapy session. Patients with a NCS-R total score during physiotherapy equal or above the score observed after the noxious stimulation could participate to the clinical trial, as well as patients with a score above 5. They received an analgesic treatment and a placebo on 2 consecutive days in a randomized order followed by an assessment with the NCS-R. Of the 18 patients, 15 displayed signs of potential pain during physiotherapy. Patients showed higher NCS-R scores during physiotherapy compared with the other conditions, suggesting that mobilizations were potentially painful. Of these 15 patients, 10 met the criteria to participate in the placebo-controlled trial. We did not find any effect of analgesic treatment on the NCS-R scores. This study highlights that physiotherapy may be potentially painful for patients with DOC, while analgesic treatments did not reduced NCS-R scores. Therefore, careful monitoring with appropriate assessment and treatment before and during mobilization should become a priority in clinical settings. Future studies should focus on the development of assessment tools sensitive to analgesic dosage to manage pain in DOC.
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Affiliation(s)
- Estelle A C Bonin
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau (C ), University Hospital, Liège, Belgium
| | - Mariachiara L Binda Fossati
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Behavioral and Nervous System Sciences Department, University of Pavia, Pavia, Italy
| | - Maria M Filippini
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Neuromotor and Rehabilitation Department, AUSL-IRCSS of Reggio Emilia, Reggio Emilia, Italy
| | - Stephen Bornheim
- Department of Sport and Rehabilitation Sciences, University of Liège, Liège, Belgium
| | - Nicolas Lejeune
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau (C ), University Hospital, Liège, Belgium
- CHN William Lennox, Saint-Luc Hospital Group, Ottignies, Belgium
- Institute of Neurosciences, UCLouvain, Brussels, Belgium
| | - Anthony T O'Brien
- Independent Scholar, Aetna, CVS Health Company, Hartford, CT, United States
| | - Olivier Bodart
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
| | - Steven Laureys
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau (C ), University Hospital, Liège, Belgium
| | - Aurore Thibaut
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau (C ), University Hospital, Liège, Belgium
| | - Camille Chatelle
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau (C ), University Hospital, Liège, Belgium
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Irzan H, Pozzi M, Chikhladze N, Cebanu S, Tadevosyan A, Calcii C, Tsiskaridze A, Melbourne A, Strazzer S, Modat M, Molteni E. Emerging Treatments for Disorders of Consciousness in Paediatric Age. Brain Sci 2022; 12:198. [PMID: 35203961 PMCID: PMC8870410 DOI: 10.3390/brainsci12020198] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/28/2022] [Accepted: 01/29/2022] [Indexed: 11/17/2022] Open
Abstract
The number of paediatric patients living with a prolonged Disorder of Consciousness (DoC) is growing in high-income countries, thanks to substantial improvement in intensive care. Life expectancy is extending due to the clinical and nursing management achievements of chronic phase needs, including infections. However, long-known pharmacological therapies such as amantadine and zolpidem, as well as novel instrumental approaches using direct current stimulation and, more recently, stem cell transplantation, are applied in the absence of large paediatric clinical trials and rigorous age-balanced and dose-escalated validations. With evidence building up mainly through case reports and observational studies, there is a need for well-designed paediatric clinical trials and specific research on 0-4-year-old children. At such an early age, assessing residual and recovered abilities is most challenging due to the early developmental stage, incompletely learnt motor and cognitive skills, and unreliable communication; treatment options are also less explored in early age. In middle-income countries, the lack of rehabilitation services and professionals focusing on paediatric age hampers the overall good assistance provision. Young and fast-evolving health insurance systems prevent universal access to chronic care in some countries. In low-income countries, rescue networks are often inadequate, and there is a lack of specialised and intensive care, difficulty in providing specific pharmaceuticals, and lower compliance to intensive care hygiene standards. Despite this, paediatric cases with DoC are reported, albeit in fewer numbers than in countries with better-resourced healthcare systems. For patients with a poor prospect of recovery, withdrawal of care is inhomogeneous across countries and still heavily conditioned by treatment costs as well as ethical and cultural factors, rather than reliant on protocols for assessment and standardised treatments. In summary, there is a strong call for multicentric, international, and global health initiatives on DoC to devote resources to the paediatric age, as there is now scope for funders to invest in themes specific to DoC affecting the early years of the life course.
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Affiliation(s)
- Hassna Irzan
- School of Biomedical Engineering & Imaging Sciences, King’s College London, London WC2R 2LS, UK; (H.I.); (A.M.); (M.M.)
- Department of Medical Physics and Biomedical Engineering, University College London, London WC1E 7JE, UK
| | - Marco Pozzi
- Scientific Institute IRCCS E. Medea, Acquired Brain Injury Unit, 22040 Bosisio Parini, Italy; (M.P.); (S.S.)
| | - Nino Chikhladze
- Faculty of Medicine, Ivane Javakhishvili Tbilisi State University, Tbilisi 0179, Georgia; (N.C.); (A.T.)
| | - Serghei Cebanu
- Faculty of Medicine, Nicolae Testemitanu State University of Medicine and Pharmacy, MD-2004 Chišināu, Moldova; (S.C.); (C.C.)
| | - Artashes Tadevosyan
- Department of Public Health and Healthcare Organization, Yerevan State Medical University, Yerevan 0025, Armenia;
| | - Cornelia Calcii
- Faculty of Medicine, Nicolae Testemitanu State University of Medicine and Pharmacy, MD-2004 Chišināu, Moldova; (S.C.); (C.C.)
| | - Alexander Tsiskaridze
- Faculty of Medicine, Ivane Javakhishvili Tbilisi State University, Tbilisi 0179, Georgia; (N.C.); (A.T.)
| | - Andrew Melbourne
- School of Biomedical Engineering & Imaging Sciences, King’s College London, London WC2R 2LS, UK; (H.I.); (A.M.); (M.M.)
- Department of Medical Physics and Biomedical Engineering, University College London, London WC1E 7JE, UK
| | - Sandra Strazzer
- Scientific Institute IRCCS E. Medea, Acquired Brain Injury Unit, 22040 Bosisio Parini, Italy; (M.P.); (S.S.)
- Rehabilitation Service, “Usratuna” Health and Rehabilitation Centre, Juba, South Sudan
| | - Marc Modat
- School of Biomedical Engineering & Imaging Sciences, King’s College London, London WC2R 2LS, UK; (H.I.); (A.M.); (M.M.)
| | - Erika Molteni
- School of Biomedical Engineering & Imaging Sciences, King’s College London, London WC2R 2LS, UK; (H.I.); (A.M.); (M.M.)
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12
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Cacciatore M, Magnani FG, Leonardi M, Rossi Sebastiano D, Sattin D. Sleep Treatments in Disorders of Consciousness: A Systematic Review. Diagnostics (Basel) 2021; 12:diagnostics12010088. [PMID: 35054255 PMCID: PMC8775271 DOI: 10.3390/diagnostics12010088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/24/2021] [Accepted: 12/30/2021] [Indexed: 12/23/2022] Open
Abstract
Sleep disorders are among the main comorbidities in patients with a Disorder of Consciousness (DOC). Given the key role of sleep in neural and cognitive functioning, detecting and treating sleep disorders in DOCs might be an effective therapeutic strategy to boost consciousness recovery and levels of awareness. To date, no systematic reviews have been conducted that explore the effect of sleep treatments in DOCs; thus, we systematically reviewed the existing studies on both pharmacological and non-pharmacological treatments for sleep disorders in DOCs. Among 2267 assessed articles, only 7 were included in the systematic review. The studies focused on two sleep disorder categories (sleep-related breathing disorders and circadian rhythm dysregulation) treated with both pharmacological (Modafinil and Intrathecal Baclofen) and non-pharmacological (positive airway pressure, bright light stimulation, and central thalamic deep brain stimulation) interventions. Although the limited number of studies and their heterogeneity do not allow generalized conclusions, all the studies highlighted the effectiveness of treatments on both sleep disorders and levels of awareness. For this reason, clinical and diagnostic evaluations able to detect sleep disorders in DOC patients should be adopted in the clinical routine for the purpose of intervening promptly with the most appropriate treatment.
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Affiliation(s)
- Martina Cacciatore
- UOC Neurologia, Salute Pubblica, Disabilità, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (M.C.); (M.L.)
| | - Francesca G. Magnani
- UOC Neurologia, Salute Pubblica, Disabilità, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (M.C.); (M.L.)
- Correspondence: ; Tel.: +39-02-23942188
| | - Matilde Leonardi
- UOC Neurologia, Salute Pubblica, Disabilità, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (M.C.); (M.L.)
| | - Davide Rossi Sebastiano
- Unità di Neurofisiopatologia, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy;
| | - Davide Sattin
- IRCCS Istituti Clinici Scientifici Maugeri di Milano, 20138 Milan, Italy;
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13
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Therapies to Restore Consciousness in Patients with Severe Brain Injuries: A Gap Analysis and Future Directions. Neurocrit Care 2021; 35:68-85. [PMID: 34236624 PMCID: PMC8266715 DOI: 10.1007/s12028-021-01227-y] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 03/04/2021] [Indexed: 02/06/2023]
Abstract
Background/Objective For patients with disorders of consciousness (DoC) and their families, the search for new therapies has been a source of hope and frustration. Almost all clinical trials in patients with DoC have been limited by small sample sizes, lack of placebo groups, and use of heterogeneous outcome measures. As a result, few therapies have strong evidence to support their use; amantadine is the only therapy recommended by current clinical guidelines, specifically for patients with DoC caused by severe traumatic brain injury. To foster and advance development of consciousness-promoting therapies for patients with DoC, the Curing Coma Campaign convened a Coma Science Work Group to perform a gap analysis. Methods We consider five classes of therapies: (1) pharmacologic; (2) electromagnetic; (3) mechanical; (4) sensory; and (5) regenerative. For each class of therapy, we summarize the state of the science, identify gaps in knowledge, and suggest future directions for therapy development. Results Knowledge gaps in all five therapeutic classes can be attributed to the lack of: (1) a unifying conceptual framework for evaluating therapeutic mechanisms of action; (2) large-scale randomized controlled trials; and (3) pharmacodynamic biomarkers that measure subclinical therapeutic effects in early-phase trials. To address these gaps, we propose a precision medicine approach in which clinical trials selectively enroll patients based upon their physiological receptivity to targeted therapies, and therapeutic effects are measured by complementary behavioral, neuroimaging, and electrophysiologic endpoints. Conclusions This personalized approach can be realized through rigorous clinical trial design and international collaboration, both of which will be essential for advancing the development of new therapies and ultimately improving the lives of patients with DoC. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-021-01227-y.
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14
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Quiñones-Ossa GA, Durango-Espinosa YA, Janjua T, Moscote-Salazar LR, Agrawal A. Persistent vegetative state: an overview. EGYPTIAN JOURNAL OF NEUROSURGERY 2021. [DOI: 10.1186/s41984-021-00111-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Disorder of consciousness diagnosis, especially when is classified as persistent vegetative state (without misestimating the other diagnosis classifications), in the intensive care is an important diagnosis to evaluate and treat. Persistent vegetative state diagnosis is a challenge in the daily clinical practice because the diagnosis is made mainly based upon the clinical history and the patient behavior observation. There are some specific criteria for this diagnosis, and this could be very tricky when the physician is not well trained.
Main body
We made a literature review regarding the persistent vegetative state diagnosis, clinical features, management, prognosis, and daily medical practice challenges while considering the bioethical issues and the family perspective about the patient status. The objective of this overview is to provide updated information regarding this clinical state’s features while considering the current medical literature available.
Conclusions
Regardless of the currently available guidelines and literature, there is still a lot of what we do not know about the persistent vegetative state. There is a lack of evidence regarding the optimal diagnosis and even more, about how to expect a natural history of this disorder of consciousness. It is important to recall that the patients (despite of their altered mental state diagnosis) should always be treated to avoid some of the intensive care unit long-stance complications.
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15
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Riganello F, Soddu A, Tonin P. Addressing Pain for a Proper Rehabilitation Process in Patients With Severe Disorders of Consciousness. Front Pharmacol 2021; 12:628980. [PMID: 33679413 PMCID: PMC7926206 DOI: 10.3389/fphar.2021.628980] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/08/2021] [Indexed: 01/18/2023] Open
Abstract
Consciousness constitutes a fundamental prerequisite in the individual appraisal and experience of pain. In the same way, a person needs to be able to report on pain perception. Patients who suffered a severe brain injury with disorders of consciousness (DOC) represent a spectrum of pathologies affecting patients' capacity to interact with the external world. In these patients, the most relevant aspects in response to pain are physiologic and behavioral. The treatments and management of pain are challenging issues in these patients, arising serious ethical concerns and bringing emotional load among medical staff, caregivers, and relatives. In this review, we report the importance of having a correct pain management in DOC patients, to individuate the best pharmacological treatment that can make the difference in detecting a behavioral response, indicative of a change in the level of consciousness, and in planning a more effective rehabilitative approach.
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Affiliation(s)
- F. Riganello
- Research in Advanced NeuroRehabilitation, Istituto Sant’Anna, Crotone, Italy
| | - A. Soddu
- Department of Physics and Astronomy, Brain and Mind Institute, Western University, London, ON, Canada
| | - P. Tonin
- Research in Advanced NeuroRehabilitation, Istituto Sant’Anna, Crotone, Italy
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16
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Li Y, He J, Yang B, Zhang H, Yang Z, Fu J, Huang L, Chen H, Yang X, Bao Y. Clinical diagnosis guidelines and neurorestorative treatment for chronic disorders of consciousness (2021 China version). JOURNAL OF NEURORESTORATOLOGY 2021. [DOI: 10.26599/jnr.2021.9040006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Chronic disorders of consciousness (DOC) include the vegetative state and the minimally consciousness state. The DOC diagnosis mainly relies on the evaluation of clinical behavioral scales, electrophysiological testing, and neuroimaging examinations. No specifically effective neurorestorative methods for chronic DOC currently exist. Any valuable exploration therapies of being able to repair functions and/or structures in the consciousness loop (e.g., drugs, hyperbaric medicines, noninvasive neurostimulation, sensory and environmental stimulation, invasive neuromodulation therapy, and cell transplantation) may become effective neurorestorative strategies for chronic DOC. In the viewpoint of Neurorestoratology, this guideline proposes the diagnostic and neurorestorative therapeutic suggestions and future exploration direction for this disease following the review of the existing treatment exploration achievements for chronic DOC.
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17
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Nardone R, Sebastianelli L, Brigo F, Golaszewski S, Trinka E, Pucks-Faes E, Saltuari L, Versace V. Effects of intrathecal baclofen therapy in subjects with disorders of consciousness: a reappraisal. J Neural Transm (Vienna) 2020; 127:1209-1215. [PMID: 32710152 DOI: 10.1007/s00702-020-02233-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 07/14/2020] [Indexed: 01/16/2023]
Abstract
Baclofen is a structural analogue of gamma-amino-butyric acid (GABA), which reduces spastic hypertonia of striated muscle due to a mechanism of GABAB-ergic inhibition of mono- and polysynaptic reflexes at the spinal level. There are reports of patients with severe disorders of consciousness that presented a substantial improvement following intrathecal baclofen (ITB) administration for severe spasticity. The neural mechanisms underlying the clinical recovery after ITB have not yet been clarified. Baclofen could modulate sleep-wake cycles that may be dysregulated and thus interfere with alertness and awareness. The diminished proprioceptive and nociceptive sensory inputs may relieve thalamo-cortical neural networks involved in maintaining the consciousness of the self and the world. ITB treatment might also promote the recovery of an impaired GABAergic cortical tone, restoring the balance between excitatory and inhibitory cortical activity. Furthermore, glutamatergic synapses are directly or indirectly modulated by GABAB-ergic receptors. Neurophysiological techniques (such as transcranial magnetic stimulation, electroencephalography, or the combination of both) can be helpful to explore the effects of intrathecal or oral baclofen on the modulation of neural cortical circuits in humans with disorders of consciousness.
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Affiliation(s)
- Raffaele Nardone
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy. .,Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria. .,Spinal Cord Injury and Tissue Regeneration Center, Salzburg, Austria. .,Karl Landsteiner Institut für Neurorehabilitation und Raumfahrtneurologie, Salzburg, Austria.
| | - Luca Sebastianelli
- Department of Neurorehabilitation, Hospital of Vipiteno, Vipiteno, Italy.,Research Unit for Neurorehabilitation South Tyrol, Bolzano, Italy
| | - Francesco Brigo
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy.,Department of Neuroscience, Biomedicine and Movement Science, University of Verona, Verona, Italy
| | - Stefan Golaszewski
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria.,Karl Landsteiner Institut für Neurorehabilitation und Raumfahrtneurologie, Salzburg, Austria
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria.,Centre for Cognitive Neurosciences Salzburg, Salzburg, Austria.,University for Medical Informatics and Health Technology, UMIT, Hall in Tirol, Austria
| | | | - Leopold Saltuari
- Department of Neurorehabilitation, Hospital of Vipiteno, Vipiteno, Italy.,Research Unit for Neurorehabilitation South Tyrol, Bolzano, Italy
| | - Viviana Versace
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy.,Research Unit for Neurorehabilitation South Tyrol, Bolzano, Italy
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18
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[Intrathecal baclofen therapy in brain injury and recovery of persistent vegetative state. Apropos of a case]. Rehabilitacion (Madr) 2020; 54:137-141. [PMID: 32370828 DOI: 10.1016/j.rh.2019.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 12/17/2019] [Accepted: 12/22/2019] [Indexed: 11/21/2022]
Abstract
Patients with brain injury and spasticity are candidates for intrathecal baclofen therapy (ITB) when maximal doses of oral antispastic drugs fail. Some authors have described an improvement in the level of consciousness in patients with brain injury and disorder of consciousness treated with ITB for spasticity. We present the case of a 43-year-old patient with brain injury, spasticity, and permanent vegetative state (PVS) who showed an improvement in the level of consciousness after ITB for spasticity. We performed an ITB infusion test, assessing the spasticity with the Modified Ashworth Scale (MAS) and level of consciousness with the Coma Recovery Scale-Revised (CRS-R) and observed an improvement in the spasticity and the level of consciousness. Consequently, the ITB pump was implanted and the patient recovered from PVS to minimal conscious state (MCS). We conclude that ITB is indicated in patients with brain injury and spasticity. We suggest the improvement in the level of consciousness as a possible additional benefit. There is a lack of evidence to recommend ITB in patients with altered level of consciousness.
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19
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Thibaut A, Schiff N, Giacino J, Laureys S, Gosseries O. Therapeutic interventions in patients with prolonged disorders of consciousness. Lancet Neurol 2019; 18:600-614. [DOI: 10.1016/s1474-4422(19)30031-6] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 01/10/2019] [Accepted: 01/10/2019] [Indexed: 12/21/2022]
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Molteni E, Slomine BS, Castelli E, Zasler N, Schnakers C, Estraneo A. International survey on diagnostic and prognostic procedures in pediatric disorders of consciousness. Brain Inj 2019; 33:517-528. [PMID: 30663416 DOI: 10.1080/02699052.2019.1565899] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
AIMS 1. to investigate diagnostic and prognostic procedures routinely used by international professionals to assess children with disorders of consciousness (DoC); 2. to explore use and availability of internal and national guidelines for pediatric DoC; 3. to identify international differences in diagnostic/prognostic protocols. METHODS The International Brain Injury Association DoC Special Interest Group emailed a survey link to 43,469 professionals. The survey included questions on diagnostic/prognostic procedures and guidelines for children with DoC. RESULTS Data on 82 respondents [(50% physicians) primarily from Europe (43.9%)and North America (37.8%)] were analyzed. Common diagnostic tools included the Glasgow Coma Scale for clinical assessment (94%), the Coma Recovery Scale-Revised for outcome measurement (57%), and cerebral MRI (94%). Clinical features used most frequently to inform prognosis varied with patient age. Few respondents used national (28%) admission protocols for children with DoC, and most were unaware of published national guidelines for diagnostic (72%) and prognostic (85%) procedures. Compared to North American respondents, more European respondents were physicians and used neurophysiological data for prognosis. CONCLUSIONS This international survey provides useful information about diagnostic and prognostic procedures currently used for children with DoC and highlights the need for guidelines to promote best practices for diagnosis/prognosis in pediatric DoC.
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Affiliation(s)
- Erika Molteni
- a Acquired Brain Injury Unit, IRCCS E. Medea , Scientific Institute , Lecco , Italy.,b School of Biomedical Engineering and Imaging Sciences , King's College London , UK
| | - Beth S Slomine
- c Department of Neuropsychology , Kennedy Krieger Institute, Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Enrico Castelli
- d Paediatric Neurorehabilitation Units, Neuroscience and Neurorehabilitation Department , Bambino Gesù Children's Hospital , Rome , Italy
| | - Nathan Zasler
- e Concussion Care Centre of Virginia, Ltd., Tree of Life Services, Inc., Department of Physical Medicine and Rehabilitation , Virginia Commonwealth University , Richmond , Virginia , USA.,f Department of Physical Medicine and Rehabilitation , University of Virginia , Charlottesville , Virginia , USA
| | - Caroline Schnakers
- g Research Institute , Casa Colina Hospital and Centers for Healthcare , Pomona , CA , USA
| | - Anna Estraneo
- h DOC Research Laboratory and Neurorehabilitation Unit for DOC patients , Maugeri Clinical Scientific Institutes, IRCCS , Telese Terme , Italy
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21
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Abstract
PURPOSE OF REVIEW Very few options exist for patients who survive severe traumatic brain injury but fail to fully recover and develop a disorder of consciousness (e.g. vegetative state, minimally conscious state). RECENT FINDINGS Among pharmacological approaches, Amantadine has shown the ability to accelerate functional recovery. Although with very low frequency, Zolpidem has shown the ability to improve the level of consciousness transiently and, possibly, also in a sustained fashion. Among neuromodulatory approaches, transcranial direct current stimulation has been shown to transiently improve behavioral responsiveness, but mostly in minimally conscious patients. New evidence for thalamic deep brain stimulation calls into question its cost/benefit trade-off. SUMMARY The growing understanding of the biology of disorders of consciousness has led to a renaissance in the development of therapeutic interventions for patients with disorders of consciousness. High-quality evidence is emerging for pharmacological (i.e. Amantadine) and neurostimulatory (i.e. transcranial direct current stimulation) interventions, although further studies are needed to delineate preconditions, optimal dosages, and timing of administration. Other exciting new approaches (e.g. low intensity focused ultrasound) still await systematic assessment. A crucial future direction should be the use of neuroimaging measures of functional and structural impairment as a means of tailoring patient-specific interventions.
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22
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Update on pharmacotherapy for stroke and traumatic brain injury recovery during rehabilitation. Curr Opin Neurol 2018; 29:700-705. [PMID: 27748687 DOI: 10.1097/wco.0000000000000381] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW This article evaluates whether specific drugs are able to facilitate motor recovery after stroke or improve the level of consciousness, cognitive, or behavioral symptoms after traumatic brain injury. RECENT FINDINGS After stroke, serotonin reuptake inhibitors can enhance restitution of motor functions in depressed as well as in nondepressed patients. Erythropoietin and progesterone administered within hours after moderate to severe traumatic brain injury failed to improve the outcome. A single dose of zolpidem can transiently improve the level of consciousness in patients with vegetative state or minimally conscious state. SUMMARY Because of the lack of large randomized controlled trials, evidence is still limited. Currently, most convincing evidence exists for fluoxetine for facilitation of motor recovery early after stroke and for amantadine for acceleration of functional recovery after severe traumatic brain injury. Methylphenidate and acetylcholinesterase inhibitors might enhance cognitive functions after traumatic brain injury. Sufficiently powered studies and the identification of predictors of beneficial drug effects are still needed.
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23
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Spasticity Management in Disorders of Consciousness. Brain Sci 2017; 7:brainsci7120162. [PMID: 29232836 PMCID: PMC5742765 DOI: 10.3390/brainsci7120162] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 12/06/2017] [Accepted: 12/07/2017] [Indexed: 11/26/2022] Open
Abstract
Background: Spasticity is a motor disorder frequently encountered after a lesion involving the central nervous system. It is hypothesized to arise from an anarchic reorganization of the pyramidal and parapyramidal fibers and leads to hypertonia and hyperreflexia of the affected muscular groups. While this symptom and its management is well-known in patients suffering from stroke, multiple sclerosis or spinal cord lesion, little is known regarding its appropriate management in patients presenting disorders of consciousness after brain damage. Objectives: Our aim was to review the occurrence of spasticity in patients with disorders of consciousness and the therapeutic interventions used to treat it. Methods: We conducted a systematic review using the PubMed online database. It returned 157 articles. After applying our inclusion criteria (i.e., studies about patients in coma, unresponsive wakefulness syndrome or minimally conscious state, with spasticity objectively reported as a primary or secondary outcome), 18 studies were fully reviewed. Results: The prevalence of spasticity in patients with disorders of consciousness ranged from 59% to 89%. Current treatment options include intrathecal baclofen and soft splints. Several treatment options still need further investigation; including acupuncture, botulin toxin or cortical activation by thalamic stimulation. Conclusion: The small number of articles available in the current literature highlights that spasticity is poorly studied in patients with disorders of consciousness although it is one of the most common motor disorders. While treatments such as intrathecal baclofen and soft splints seem effective, large randomized controlled trials have to be done and new therapeutic options should be explored.
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24
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Sutton JA, Clauss RP. A review of the evidence of zolpidem efficacy in neurological disability after brain damage due to stroke, trauma and hypoxia: A justification of further clinical trials. Brain Inj 2017; 31:1019-1027. [PMID: 28534652 DOI: 10.1080/02699052.2017.1300836] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
During 15 years, 23 clinical reports and 6 studies have demonstrated associations between sub-sedative doses of zolpidem and recoveries from brain damage due to strokes, trauma and hypoxia. Clinical findings include unexpected awakenings from vegetative states and regressions of stroke symptoms after dosing that disappear during elimination and reappear on repeat dosing. Initially single-photon emission computed tomography scans showed improved perfusion within, around and distant from infarctions. Then positron emission tomography scans and electroencephalography detected renewed metabolic and neuronal activity. Placebo or a similar, gamma-aminobutyric acid (GABA)-ergic, sedative zopiclone has no such effect. The effect appears only several months after the injury, reflecting recent evidence in mice of substantial differences between the states of GABA receptors in acute and chronic repair phases of recovery. Zolpidem's good safety record and rapid absorption further indicate a need for more clinical trials. List of acronyms: BOLD, Blood-Oxygen-Level Dependent contrast imaging in MRI; CRS, Coma Recovery Scale; CRS-R, Coma Recovery Scale Revised; CSI, Cerebral State Index; CSM, Cerebral State Monitor; DOC, Disorder of Consciousness; EEG, Electro Encephalography; FDG-PET, FluoroDeoxyGlucose-Positron Emission Tomography; FTD, Frontotemporal dementia; GABA, Gamma-Aminobutyric Acid; MCS, Minimally Conscious State; M-EEG, Magneto-Encephalography; MRI, Magnetic Resonance Image; MSN, Median Spiny Neurones; PET, Positron Emission Tomography; PVS, Persistent Vegetative Sate; RLAC, Rancho Los Amigos Cognitive scores; SPECT, Single-photon emission computed tomography; TFES, Tinetti Falls Efficacy Scale; 99mTc HMPAO, Technetium hexamethylpropyleneamine oxime.
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Affiliation(s)
- J A Sutton
- a ReGen Therapeutics plc and Guildford Clinical Pharmacology Ltd. , Midhurst , West Sussex , UK
| | - R P Clauss
- b Department of Nuclear Medicine , Royal Surrey County Hospital , Guildford , Surrey , UK
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Maneyapanda MB, McCormick ZL, Marciniak C, Reger C. Long-Term Dosing of Intrathecal Baclofen in the Treatment of Spasticity After Acquired Brain Injury. PM R 2017; 9:556-562. [DOI: 10.1016/j.pmrj.2016.12.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Revised: 12/13/2016] [Accepted: 12/17/2016] [Indexed: 01/12/2023]
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26
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Wang ZM, Law JH, King NKK, Rajeswaran DK, Soh S, Rao JP, Ng WH, Chua KSG. Treatment of severe, disabling spasticity with continuous intrathecal baclofen therapy following acquired brain injury: the experience of a tertiary institution in Singapore. Singapore Med J 2016; 57:8-12. [PMID: 26831310 DOI: 10.11622/smedj.2016005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Intrathecal baclofen (ITB) therapy is a proven, effective treatment for disabling cortical spasticity. We describe the first local series of five patients with acquired brain injury (ABI) who received ITB and were followed up for 63.8 months. METHODS A retrospective review of medical and rehabilitation records of patients who received ITB therapy was carried out. Data studied included baseline demographic and injury variables, implantation data, spasticity and function, ITB dosage over time and complications. RESULTS From 2006 to 2010, a total of five patients received ITB therapy via implanted pumps about 39.4 months after ABI. Four out of five patients experienced significant reductions in their lower limb spasticity scores and improvements in global function and dependency. One patient had minor adverse events associated with baclofen-related sedation. The mean ITB dose at one year was 182.7 ± 65.6 mcg/day. CONCLUSION Our preliminary study showed encouraging long-term outcomes and safety for ITB therapy after ABI-related intractable spasticity. Individual ITB responses over time were variable, with gender differences. The outcomes experienced by our centre were comparable to those in the general ABI population, supporting the efficacy of ITB therapy for chronic disabling spasticity.
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Affiliation(s)
- Zhe Min Wang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jia Hao Law
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | | | - Samantha Soh
- Department of Neurosurgery, National Neuroscience Institute, Singapore
| | - Jai Prashanth Rao
- Department of Neurosurgery, National Neuroscience Institute, Singapore
| | - Wai Hoe Ng
- Department of Neurosurgery, National Neuroscience Institute, Singapore
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Bodien YG, Carlowicz CA, Chatelle C, Giacino JT. Sensitivity and Specificity of the Coma Recovery Scale--Revised Total Score in Detection of Conscious Awareness. Arch Phys Med Rehabil 2015; 97:490-492.e1. [PMID: 26342571 DOI: 10.1016/j.apmr.2015.08.422] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 08/16/2015] [Accepted: 08/18/2015] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To describe the sensitivity and specificity of Coma Recovery Scale-Revised (CRS-R) total scores in detecting conscious awareness. DESIGN Data were retrospectively extracted from the medical records of patients enrolled in a specialized disorders of consciousness (DOC) program. Sensitivity and specificity analyses were completed using CRS-R-derived diagnoses of minimally conscious state (MCS) or emerged from minimally conscious state (EMCS) as the reference standard for conscious awareness and the total CRS-R score as the test criterion. A receiver operating characteristic curve was constructed to demonstrate the optimal CRS-R total cutoff score for maximizing sensitivity and specificity. SETTING Specialized DOC program. PARTICIPANTS Patients enrolled in the DOC program (N=252, 157 men; mean age, 49y; mean time from injury, 48d; traumatic etiology, n=127; nontraumatic etiology, n=125; diagnosis of coma or vegetative state, n=70; diagnosis of MCS or EMCS, n=182). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Sensitivity and specificity of CRS-R total scores in detecting conscious awareness. RESULTS A CRS-R total score of 10 or higher yielded a sensitivity of .78 for correct identification of patients in MCS or EMCS, and a specificity of 1.00 for correct identification of patients who did not meet criteria for either of these diagnoses (ie, were diagnosed with vegetative state or coma). The area under the curve in the receiver operating characteristic curve analysis is .98. CONCLUSIONS A total CRS-R score of 10 or higher provides strong evidence of conscious awareness but resulted in a false-negative diagnostic error in 22% of patients who demonstrated conscious awareness based on CRS-R diagnostic criteria. A cutoff score of 8 provides the best balance between sensitivity and specificity, accurately classifying 93% of cases. The optimal total score cutoff will vary depending on the user's objective.
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Affiliation(s)
- Yelena G Bodien
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital-Harvard Medical School, Charlestown, MA.
| | - Cecilia A Carlowicz
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital-Harvard Medical School, Charlestown, MA
| | - Camille Chatelle
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital-Harvard Medical School, Charlestown, MA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital-Harvard Medical School, Charlestown, MA
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Pistoia F, Sacco S, Sarà M, Franceschini M, Carolei A. Intrathecal baclofen: effects on spasticity, pain, and consciousness in disorders of consciousness and locked-in syndrome. Curr Pain Headache Rep 2015; 19:466. [PMID: 25416459 DOI: 10.1007/s11916-014-0466-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Disorders of consciousness (DOCs) include coma, vegetative state (VS), and minimally conscious state (MCS). Coma is characterized by impaired wakefulness and consciousness, while VS and MCS are defined by lacking or discontinuous consciousness despite recovered wakefulness. Conversely, locked-in syndrome (LIS) is characterized by quadriplegia and lower cranial nerve paralysis with preserved consciousness. Intrathecal baclofen (ITB) is a useful treatment to improve spasticity both in patients with DOCs and LIS. Moreover, it supports the recovery of consciousness in some patients with VS or MCS. The precise mechanism underlying this recovery has not yet been elucidated. It has been hypothesized that ITB may act by reducing the overload of dysfunctional sensory stimuli reaching the injured brain or by stabilizing the imbalanced circadian rhythms. Although the current indication of ITB is the management of severe spasticity, its potential use in speeding the recovery of consciousness merits further investigation.
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Affiliation(s)
- Francesca Pistoia
- Neurological Institute, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Via Vetoio, 67100, L'Aquila, Italy,
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Assessment of patients with disorder of consciousness: do different Coma Recovery Scale scoring correlate with different settings? J Neurol 2014; 261:2378-86. [DOI: 10.1007/s00415-014-7478-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 08/20/2014] [Accepted: 08/21/2014] [Indexed: 12/11/2022]
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