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Pingue V, Mirando M, Cazzulani B, Bellaviti G, Saporiti F, Zanga C, Nardone A. Neck muscle spasticity in patients with disorder of consciousness: a pilot study. Eur J Phys Rehabil Med 2024; 60:412-419. [PMID: 38502553 PMCID: PMC11255878 DOI: 10.23736/s1973-9087.24.08176-0] [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] [Received: 08/05/2023] [Revised: 01/15/2024] [Accepted: 02/22/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND Disorder of consciousness (DOC) is a state of prolonged altered consciousness due to severe acquired brain injury (ABI). DOC can be differentiated into coma, unresponsive wakefulness syndrome (UWS), or minimally conscious state (MCS) depending on the behavioral features observed and their relationship to the level of consciousness. Spasticity is one of the most frequently reported medical comorbidities in DOC patients. Since there is a critical lack of spasticity-focused studies and, in turn, of target treatment, we designed this pilot prospective study to evaluate cervical spine muscle spasticity and its effect on rehabilitation outcome in a large cohort of patients followed from the post-acute phase to 6 months after severe ABI. AIM To evaluate neck muscle spasticity and investigate its impact on neurological and functional outcome in a large cohort of adult patients with DOC followed from post-acute to 6 months after severe ABI. DESIGN Single-center prospective pilot study. SETTING Highly specialized inpatient neurorehabilitation clinic. POPULATION Patients with severe ABI admitted within 3 months after the acute event to our Neurorehabilitation Unit between May 21st, 2019 and April 23rd, 2020 for treatment of DOC as a part of their rehabilitation program. METHODS In this single-center prospective pilot study demographic data, etiology of ABI (traumatic versus non-traumatic), DOC evaluated with the revised Coma Recovery Scale (CRS-R), and neurological and functional outcome assessed respectively with the Glasgow Coma Scale (GCS) and Functional Independence Measure (FIM) were considered. During cervical examination, we assessed spasticity with the Modified Ashworth Scale (MAS), deviation of head alignment with a goniometer, and pain with the Nociception Coma Scale-Revised (NCS-R). RESULTS Of the 48 patients, 41.7% were diagnosed with UWS and 58.3% were in a minimally conscious state (MCS). We found spasticity of neck muscles in 91.7% of patients, with no difference in severity (assessed with MAS) between UWV and MCS. The NCS-R score at cervical spine examination was lower in UWS than MCS. Spasticity was severer in patients with traumatic brain injury (TBI) compared to non-traumatic. At multiple linear regression analysis, younger age, hemisyndrome, and tetraparesis were independent predictors of severity of neck muscle spasticity in MCS. More severe spasticity was a predictor of worse neurological and functional outcome at discharge in UWS patients, independently of the other confounding variables at admission (e.g., age, severity of brain injury, functional assessment, and pain). CONCLUSIONS Spasticity of neck muscles frequently develops in patients with DOC and is more severe in those after TBI. UWV and MCS have different spasticity profiles as regards risk factors and neurological and functional outcome. Severity of neck muscle spasticity in UWV patients may represent an early indicator of worse neurological and functional outcome after inpatient rehabilitation. CLINICAL REHABILITATION IMPACT Our findings could prompt clinicians to redefine the rehabilitation aims regarding spasticity and to estimate the functional outcome in patients undergoing intensive rehabilitation after severe ABI.
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Affiliation(s)
- Valeria Pingue
- Neurorehabilitation and Spinal Unit, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy -
| | - Marta Mirando
- Centro Studi Attività Motorie (CSAM), ICS Maugeri SPA SB, Institute of Pavia, IRCCS, Pavia, Italy
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Benedetta Cazzulani
- Neurorehabilitation and Spinal Unit, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Gianluca Bellaviti
- Neurorehabilitation and Spinal Unit, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Filippo Saporiti
- Department of Neuroscience, Division of Specialistic Rehabilitation, ASST Ovest Milanese, Legnano, Milan, Italy
| | - Cristina Zanga
- Neurorehabilitation and Spinal Unit, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Antonio Nardone
- Neurorehabilitation and Spinal Unit, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
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Appel A, Spier E. Strategy and Philosophy for Treating Pain and Sleep in Disorders of Consciousness. Phys Med Rehabil Clin N Am 2024; 35:145-154. [PMID: 37993184 DOI: 10.1016/j.pmr.2023.06.022] [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: 11/24/2023]
Abstract
Despite the evolving practice of brain injury medicine, consciousness remains enigmatic. Most patients with disorders of consciousness have disordered sleep and return of normal sleep architecture is essential to the emergence of consciousness and the healing brain. In this article we lay a framework for understanding the emergence of consciousness in brain-injured patients. We then explore ways to use that framework to evaluate and tailor treatment of sleep and pain in patients with disorders of consciousness. Although more research is needed to empower better treatment in the future, validated tools now exist for evaluation of emergent consciousness, pain, and sleep.
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Affiliation(s)
- Amanda Appel
- Department of Pediatric Rehabilitation Medicine, Children's Hospital Colorado, Aurora, CO, USA; Department of Pediatrics, Children's Hospital Colorado, Aurora, CO, USA; Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz School of Medicine, Aurora, CO, USA
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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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Riganello F, Tonin P, Soddu A. I Feel! Therefore, I Am from Pain to Consciousness in DOC Patients. Int J Mol Sci 2023; 24:11825. [PMID: 37511583 PMCID: PMC10380260 DOI: 10.3390/ijms241411825] [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: 06/21/2023] [Revised: 07/13/2023] [Accepted: 07/20/2023] [Indexed: 07/30/2023] Open
Abstract
Pain assessment and management in patients with disorders of consciousness (DOC) is a challenging and important aspect of care, with implications for detecting consciousness and promoting recovery. This narrative review explores the role of pain in consciousness, the challenges of pain assessment, pharmacological treatment in DOC, and the implications of pain assessment when detecting changes in consciousness. The review discusses the Nociception Coma Scale and its revised version, which are behavioral scales used to assess pain in DOC patients, and the challenges and controversies surrounding the appropriate pharmacological treatment of pain in these patients. Moreover, we highlight recent evidence suggesting that an accurate pain assessment may predict changes in the level of consciousness in unresponsive wakefulness syndrome/vegetative state patients, underscoring the importance of ongoing pain management in these patients.
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Affiliation(s)
- Francesco Riganello
- Research in Advanced Neurorehabilitation, S. Anna Institute, 88900 Crotone, Italy
| | - Paolo Tonin
- Research in Advanced Neurorehabilitation, S. Anna Institute, 88900 Crotone, Italy
| | - Andrea Soddu
- Physics, and Astronomy Department, Western Institute for Neuroscience, University of Western Ontario, London, ON N6A 3K7, Canada
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Bonin EAC, Lejeune N, Szymkowicz E, Bonhomme V, Martial C, Gosseries O, Laureys S, Thibaut A. Assessment and management of pain/nociception in patients with disorders of consciousness or locked-in syndrome: A narrative review. Front Syst Neurosci 2023; 17:1112206. [PMID: 37021037 PMCID: PMC10067681 DOI: 10.3389/fnsys.2023.1112206] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/06/2023] [Indexed: 04/07/2023] Open
Abstract
The assessment and management of pain and nociception is very challenging in patients unable to communicate functionally such as patients with disorders of consciousness (DoC) or in locked-in syndrome (LIS). In a clinical setting, the detection of signs of pain and nociception by the medical staff is therefore essential for the wellbeing and management of these patients. However, there is still a lot unknown and a lack of clear guidelines regarding the assessment, management and treatment of pain and nociception in these populations. The purpose of this narrative review is to examine the current knowledge regarding this issue by covering different topics such as: the neurophysiology of pain and nociception (in healthy subjects and patients), the source and impact of nociception and pain in DoC and LIS and, finally, the assessment and treatment of pain and nociception in these populations. In this review we will also give possible research directions that could help to improve the management of this specific population of severely brain damaged patients.
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Affiliation(s)
- Estelle A. C. Bonin
- Coma Science Group, GIGA-Consciousness Thematic Unit, GIGA-Research, Liège, Belgium
- Centre du Cerveau, Liège University Hospital, Liège, Belgium
| | - Nicolas Lejeune
- Coma Science Group, GIGA-Consciousness Thematic Unit, GIGA-Research, Liège, Belgium
- Centre Hospitalier Neurologique (CHN) William Lennox, Saint-Luc Hospital Group, Ottignies-Louvain-la-Neuve, Belgium
- Institute of Neuroscience, Université catholique de Louvain, Brussels, Belgium
| | - Emilie Szymkowicz
- Coma Science Group, GIGA-Consciousness Thematic Unit, GIGA-Research, Liège, Belgium
- Centre du Cerveau, Liège University Hospital, Liège, Belgium
| | - Vincent Bonhomme
- Department of Anesthesia and Intensive Care Medicine, Liège University Hospital, Liège, Belgium
- Anesthesia and Perioperative Neuroscience Laboratory, GIGA-Consciousness Thematic Unit, GIGA-Research, Liège, Belgium
| | - Charlotte Martial
- Coma Science Group, GIGA-Consciousness Thematic Unit, GIGA-Research, Liège, Belgium
- Centre du Cerveau, Liège University Hospital, Liège, Belgium
| | - Olivia Gosseries
- Coma Science Group, GIGA-Consciousness Thematic Unit, GIGA-Research, Liège, Belgium
- Centre du Cerveau, Liège University Hospital, Liège, Belgium
| | - Steven Laureys
- Coma Science Group, GIGA-Consciousness Thematic Unit, GIGA-Research, Liège, Belgium
- Centre du Cerveau, Liège University Hospital, Liège, Belgium
- Joint International Research Unit on Consciousness, CERVO Brain Research Centre, Centre Intégré Universitaire de Santé et Services Sociaux (CIUSS), University Laval, Québec City, QC, Canada
| | - Aurore Thibaut
- Coma Science Group, GIGA-Consciousness Thematic Unit, GIGA-Research, Liège, Belgium
- Centre du Cerveau, Liège University Hospital, Liège, Belgium
- *Correspondence: Aurore Thibaut,
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Understanding, detecting, and stimulating consciousness recovery in the ICU. Acta Neurochir (Wien) 2022; 165:809-828. [PMID: 36242637 DOI: 10.1007/s00701-022-05378-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/07/2022] [Indexed: 11/01/2022]
Abstract
Coma is a medical and socioeconomic emergency. Although underfunded, research on coma and disorders of consciousness has made impressive progress. Lesion-network-mapping studies have delineated the precise brainstem regions that consistently produce coma when damaged. Functional neuroimaging has revealed how mechanisms like "communication through coherence" and "inhibition by gating" work in synergy to enable cortico-cortical processing and how this information transfer is disrupted in brain injury. On the cellular level, break-down of intracellular communication between the layer 5 pyramidal cell soma and the apical dendritic part impairs dendritic information integration, with up-stream effects on microcircuits in local neuronal populations and on large-scale fronto-parietal networks, which correlates with loss of consciousness. A breakthrough in clinical concepts occurred when fMRI, and later EEG, studies revealed that 15% of clinically unresponsive patients in acute and chronic settings are in fact awake and aware, as shown by their command following abilities revealed by brain activation during motor and locomotion imagery tasks. This condition is now termed "cognitive motor dissociation." Furthermore, epidemiological data on coma were literally non-existent until recently because of difficulties related to case ascertainment with traditional methods, but crowdsourcing of family observations enabled the first estimates of how frequent coma is in the general population (pooled annual incidence of 201 coma cases per 100,000 population in the UK and the USA). Diagnostic guidelines on coma and disorders of consciousness by the American Academy of Neurology and the European Academy of Neurology provide ambitious clinical frameworks to accommodate these achievements. As for therapy, a broad range of medical and non-medical treatment options is now being tested in increasingly larger trials; in particular, amantadine and transcranial direct current stimulation appear promising in this regard. Major international initiatives like the Curing Coma Campaign aim to raise awareness for coma and disorders of consciousness in the public, with the ultimate goal to make more brain-injured patients recover consciousness after a coma. To highlight all these accomplishments, this paper provides a comprehensive overview of recent progress and future challenges related to understanding, detecting, and stimulating consciousness recovery in the ICU.
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Shen J, Tang S, Yan B, Xie D, Fang T, Chen L, Li G. Pain assessment during physiotherapy and noxious stimuli in patients with disorders of consciousness: A preliminary study. Front Integr Neurosci 2022; 16:962077. [PMID: 36159090 PMCID: PMC9492971 DOI: 10.3389/fnint.2022.962077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 08/22/2022] [Indexed: 12/03/2022] Open
Abstract
Objectives The primary purpose of this study is to determine whether patients with disorders of consciousness (DOC) (unresponsive wakefulness syndrome, UWS; minimally conscious state, MCS) experience pain during physiotherapy and noxious stimuli in a larger patient population. Materials and methods The patients’ level of consciousness was measured with the Coma Recovery Scale-Revised (CRS-R). Additionally, the Nociception Coma Scale-revised (NCS-R) was used to assess their pain response. The NCS-R total scores between UWS and MCS at baseline, physiotherapy and noxious stimulus were compared using the Mann-Whitney U test (Wilcoxon rank-sum test) and the Kruskal-Wallis H test with Bonferroni correction. Results The study enrolled 93 participants. There was a statistically significant difference in NCS-R total scores between the three conditions (H = 215.25, p < 0.001). At baseline, there was no statistically significant difference between MCS and UWS (U = 378, z = –1.35, p = 0.178). While there was a statistically significant difference between MCS and UWS during physiotherapy (U = 1,362, z = –3.06, p < 0.01) and under noxious stimuli (U = 5142.5, z = –11.22, p < 0.001). Conclusion Physiotherapy improved the activity responsiveness of DOC patients, and patients experienced less potential pain. However, some DOC patients, especially MCS patients, perceived pain under the noxious stimuli.
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Kondziella D, Stevens RD. Classifying Disorders of Consciousness: Past, Present, and Future. Semin Neurol 2022; 42:239-248. [PMID: 35738291 DOI: 10.1055/a-1883-1021] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Pain in Persons with Disorders of Consciousness. Brain Sci 2022; 12:brainsci12030300. [PMID: 35326257 PMCID: PMC8946117 DOI: 10.3390/brainsci12030300] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 02/14/2022] [Accepted: 02/18/2022] [Indexed: 02/06/2023] Open
Abstract
Pain and suffering in persons with disorders of consciousness (DoC) remain poorly understood, frequently unaddressed or inadequately addressed, and controversial on numerous levels. This narrative literature review will address a number of critical issues germane to pain and suffering in this challenging group of patients, providing an introductory overview of the topic, perspectives on current knowledge regarding pain pathoanatomy and pathophysiology, and a review of common pain generators and factors that can lead to the chronifcation of pain. Caveats on bedside pain assessment challenges, as well as electrophysiologic and neuroimaging findings in these patients, will also be explored. Pain management techniques, including non-pharmacological and pharmacological, will be reviewed. Ethical considerations in the context of pain and suffering in persons with disorders of consciousness will round out the review prior to our concluding comments.
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Cortese MD, Arcuri F, Nemirovsky IE, Lucca LF, Tonin P, Soddu A, Riganello F. Nociceptive Response Is a Possible Marker of Evolution in the Level of Consciousness in Unresponsive Wakefulness Syndrome Patients. Front Neurosci 2021; 15:771505. [PMID: 34975378 PMCID: PMC8714733 DOI: 10.3389/fnins.2021.771505] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 11/15/2021] [Indexed: 11/13/2022] Open
Abstract
The Nociception Coma Scale (NCS) and its revised version (NCS-R) were used to evaluate behavioral responses to pain in non-communicative patients. We hypothesized that if patients demonstrate changes to their NCS(-R) scores over time, their evolving behavioral abilities could indicate a forthcoming diagnostic improvement with the Coma Recovery Scale-Revised (CRS-R). Forty-three Vegetative State/Unresponsive Wakefulness Syndrome (VS/UWS) patients were enrolled in the study. The patients were assessed weekly using the CRS-R and NCS(-R) for four consecutive weeks. The first assessment was within 10 days after hospitalization. The assessments were performed between 09:30 and 11:30 AM in a room with constant levels of humidity, light and temperature, as well as an absence of transient noise. Noxious stimuli were administered using a Newton-meter, with pressure applied to the fingernail bed for a maximum of 5 s unless interrupted by a behavioral response from subjects. Seventeen patients demonstrated improvements in their level of consciousness, 13 of whom showed significant behavioral changes through the NCS(-R) before being diagnosed with a Minimally Conscious State (MCS) according to the CRS-R. The behavioral changes observed using the NCS(-R) corresponded to a high probability of observing an improvement from VS/UWS to MCS. To characterize the increased likelihood of this transition, our results present threshold scores of ≥5 for the NCS (accuracy 86%, sensitivity 87%, and specificity 86%) and ≥3 for the NCS-R (accuracy 77%, sensitivity 89%, and specificity 73%). In conclusion, a careful evaluation of responses to nociceptive stimuli in DOC patients could constitute an effective procedure in assessing their evolving conscious state.
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Affiliation(s)
- Maria Daniela Cortese
- Research in Advanced Neurorehabilitation (RAN), S. Anna Institute, Via Siris, Crotone, Italy
| | - Francesco Arcuri
- Research in Advanced Neurorehabilitation (RAN), S. Anna Institute, Via Siris, Crotone, Italy
| | - Idan E. Nemirovsky
- Department of Physics and Astronomy, Brain and Mind Institute, Western University, London, ON, Canada
| | - Lucia Francesca Lucca
- Research in Advanced Neurorehabilitation (RAN), S. Anna Institute, Via Siris, Crotone, Italy
| | - Paolo Tonin
- Research in Advanced Neurorehabilitation (RAN), S. Anna Institute, Via Siris, Crotone, Italy
| | - Andrea Soddu
- Department of Physics and Astronomy, Brain and Mind Institute, Western University, London, ON, Canada
| | - Francesco Riganello
- Research in Advanced Neurorehabilitation (RAN), S. Anna Institute, Via Siris, Crotone, Italy
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Pain Perception in Disorder of Consciousness: A Scoping Review on Current Knowledge, Clinical Applications, and Future Perspective. Brain Sci 2021; 11:brainsci11050665. [PMID: 34065349 PMCID: PMC8161058 DOI: 10.3390/brainsci11050665] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 05/05/2021] [Accepted: 05/19/2021] [Indexed: 01/18/2023] Open
Abstract
Pain perception in individuals with prolonged disorders of consciousness (PDOC) is still a matter of debate. Advanced neuroimaging studies suggest some cortical activations even in patients with unresponsive wakefulness syndrome (UWS) compared to those with a minimally conscious state (MCS). Therefore, pain perception has to be considered even in individuals with UWS. However, advanced neuroimaging assessment can be challenging to conduct, and its findings are sometimes difficult to be interpreted. Conversely, multichannel electroencephalography (EEG) and laser-evoked potentials (LEPs) can be carried out quickly and are more adaptable to the clinical needs. In this scoping review, we dealt with the neurophysiological basis underpinning pain in PDOC, pointing out how pain perception assessment in these individuals might help in reducing the misdiagnosis rate. The available literature data suggest that patients with UWS show a more severe functional connectivity breakdown among the pain-related brain areas compared to individuals in MCS, pointing out that pain perception increases with the level of consciousness. However, there are noteworthy exceptions, because some UWS patients show pain-related cortical activations that partially overlap those observed in MCS individuals. This suggests that some patients with UWS may have residual brain functional connectivity supporting the somatosensory, affective, and cognitive aspects of pain processing (i.e., a conscious experience of the unpleasantness of pain), rather than only being able to show autonomic responses to potentially harmful stimuli. Therefore, the significance of the neurophysiological approach to pain perception in PDOC seems to be clear, and despite some methodological caveats (including intensity of stimulation, multimodal paradigms, and active vs. passive stimulation protocols), remain to be solved. To summarize, an accurate clinical and neurophysiological assessment should always be performed for a better understanding of pain perception neurophysiological underpinnings, a more precise differential diagnosis at the level of individual cases as well as group comparisons, and patient-tailored management.
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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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Bonin EA, Lejeune N, Thibaut A, Cassol H, Antonopoulos G, Wannez S, Martial C, Schnakers C, Laureys S, Chatelle C. Nociception Coma Scale-Revised Allows to Identify Patients With Preserved Neural Basis for Pain Experience. THE JOURNAL OF PAIN 2020; 21:742-750. [DOI: 10.1016/j.jpain.2019.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 09/05/2019] [Accepted: 11/11/2019] [Indexed: 01/18/2023]
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14
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Cortese D, Riganello F, Arcuri F, Lucca L, Tonin P, Schnakers C, Laureys S. The Trace Conditional Learning of the Noxious Stimulus in UWS Patients and Its Prognostic Value in a GSR and HRV Entropy Study. Front Hum Neurosci 2020; 14:97. [PMID: 32327985 PMCID: PMC7161674 DOI: 10.3389/fnhum.2020.00097] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 03/02/2020] [Indexed: 01/18/2023] Open
Abstract
The assessment of the consciousness level of Unresponsive Wakefulness Syndrome (UWS) patients often depends on a subjective interpretation of the observed spontaneous and volitional behavior. To date, the misdiagnosis level is around 30%. The aim of this study was to observe the behavior of UWS patients, during the administration of noxious stimulation by a Trace Conditioning protocol, assessed by the Galvanic Skin Response (GSR) and Heart Rate Variability (HRV) entropy. We recruited 13 Healthy Control (HC) and 30 UWS patients at 31 ± 9 days from the acute event evaluated by Coma Recovery Scale–Revised (CRS-R) and Nociception Coma Scale (NCS). Two different stimuli [musical stimulus (MUS) and nociceptive stimulus (NOC)], preceded, respectively by two different tones, were administered following the sequences (A) MUS1 – NOC1 – MUS2 – MUS3 – NOC2 – MUS4 – NOC3 – NOC*, and (B) MUS1*, NOC1*, NOC2*, MUS2*, NOC3*, MUS3*, NOC4*, MUS4*. All the (*) indicate the only tones administration. CRS-R and NCS assessments were repeated for three consecutive weeks. MUS4, NOC3, and NOC* were compared for GSR wave peak magnitude, time to reach the peak, and time of wave's decay by Wilcoxon's test to assess the Conditioned Response (CR). The Sample Entropy (SampEn) was recorded in baseline and both sequences. Machine Learning approach was used to identify a rule to discriminate the CR. The GSR magnitude of CR was higher comparing music stimulus (p < 0.0001) and CR extinction (p < 0.002) in nine patients and in HC. Patients with CR showed a higher SampEn in sequence A compared to patients without CR. Within the third and fourth weeks from protocol administration, eight of the nine patients (88.9%) evolved into MCS. The Machine-learning showed a high performance to differentiate presence/absence of CR (≥95%). The possibility to observe the CR to the noxious stimulus, by means of the GSR and SampEn, can represent a potential method to reduce the misdiagnosis in UWS patients.
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Affiliation(s)
- Daniela Cortese
- Research in Advanced NeuroRehabilitation, Istituto Sant'Anna, Crotone, Italy
| | - Francesco Riganello
- Research in Advanced NeuroRehabilitation, Istituto Sant'Anna, Crotone, Italy.,Coma Science Group, GIGA-Consciousness, University & Hospital of Liege, Liege, Belgium
| | - Francesco Arcuri
- Research in Advanced NeuroRehabilitation, Istituto Sant'Anna, Crotone, Italy
| | - Lucia Lucca
- Research in Advanced NeuroRehabilitation, Istituto Sant'Anna, Crotone, Italy
| | - Paolo Tonin
- Research in Advanced NeuroRehabilitation, Istituto Sant'Anna, Crotone, Italy
| | - Caroline Schnakers
- Neurosurgery Department, University of California, Los Angeles, Los Angeles, CA, United States.,Research Institute, Casa Colina Hospital and Centers of Healthcare, Pomona, CA, United States
| | - Steven Laureys
- Coma Science Group, GIGA-Consciousness, University & Hospital of Liege, Liege, Belgium
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15
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Aubinet C, Cassol H, Gosseries O, Bahri MA, Larroque SK, Majerus S, Martial C, Martens G, Carrière M, Chatelle C, Laureys S, Thibaut A. Brain Metabolism but Not Gray Matter Volume Underlies the Presence of Language Function in the Minimally Conscious State (MCS): MCS+ Versus MCS- Neuroimaging Differences. Neurorehabil Neural Repair 2020; 34:172-184. [PMID: 31971884 DOI: 10.1177/1545968319899914] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background. The minimally conscious state (MCS) is subcategorized into MCS- and MCS+, depending on the absence or presence, respectively, of high-level behavioral responses such as command-following. Objective. We aim to investigate the functional and structural neuroanatomy underlying the presence of these responses in MCS- and MCS+ patients. Methods. In this cross-sectional retrospective study, chronic MCS patients were diagnosed using repeated Coma Recovery Scale-Revised assessments. Fluorodeoxyglucose-positron emission tomography data were acquired on 57 patients (16 MCS-; 41 MCS+) and magnetic resonance imaging with voxel-based morphometry analysis was performed on 66 patients (17 MCS-; 49 MCS+). Brain glucose metabolism and gray matter integrity were compared between patient groups and control groups. A metabolic functional connectivity analysis testing the hypothesis of preserved language network in MCS+ compared with MCS- was also done. Results. Patients in MCS+ presented higher metabolism mainly in the left middle temporal cortex, known to be important for semantic processing, compared with the MCS- group. The left angular gyrus was also functionally disconnected from the left prefrontal cortex in MCS- compared with MCS+ group. No significant differences were found in gray matter volume between patient groups. Conclusions. The clinical subcategorization of MCS is supported by differences in brain metabolism but not in gray matter structure, suggesting that brain function in the language network is the main support for recovery of command-following, intelligible verbalization and/or intentional communication in the MCS. Better characterizing the neural correlates of residual cognitive abilities of MCS patients contributes to reduce their misdiagnosis and to adapt therapeutic approaches.
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Affiliation(s)
- Charlène Aubinet
- Coma Science Group, GIGA-Consciousness, University of Liège, Liege, Belgium.,Centre du Cerveau², University Hospital of Liège, Liege, Belgium
| | - Helena Cassol
- Coma Science Group, GIGA-Consciousness, University of Liège, Liege, Belgium.,Centre du Cerveau², University Hospital of Liège, Liege, Belgium
| | - Olivia Gosseries
- Coma Science Group, GIGA-Consciousness, University of Liège, Liege, Belgium.,Centre du Cerveau², University Hospital of Liège, Liege, Belgium
| | - Mohamed Ali Bahri
- GIGA-Cyclotron Research Center In Vivo Imaging, University of Liège, Liege, Belgium
| | - Stephen Karl Larroque
- Coma Science Group, GIGA-Consciousness, University of Liège, Liege, Belgium.,Centre du Cerveau², University Hospital of Liège, Liege, Belgium
| | - Steve Majerus
- Psychology and Neuroscience of Cognition Research Unit, University of Liège, Liege, Belgium
| | - Charlotte Martial
- Coma Science Group, GIGA-Consciousness, University of Liège, Liege, Belgium.,Centre du Cerveau², University Hospital of Liège, Liege, Belgium
| | - Géraldine Martens
- Coma Science Group, GIGA-Consciousness, University of Liège, Liege, Belgium.,Centre du Cerveau², University Hospital of Liège, Liege, Belgium
| | - Manon Carrière
- Coma Science Group, GIGA-Consciousness, University of Liège, Liege, Belgium.,Centre du Cerveau², University Hospital of Liège, Liege, Belgium
| | - Camille Chatelle
- Coma Science Group, GIGA-Consciousness, University of Liège, Liege, Belgium.,Centre du Cerveau², University Hospital of Liège, Liege, Belgium
| | - Steven Laureys
- Coma Science Group, GIGA-Consciousness, University of Liège, Liege, Belgium.,Centre du Cerveau², University Hospital of Liège, Liege, Belgium
| | - Aurore Thibaut
- Coma Science Group, GIGA-Consciousness, University of Liège, Liege, Belgium.,Centre du Cerveau², University Hospital of Liège, Liege, Belgium
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16
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Thibaut A, Piarulli A, Martens G, Chatelle C, Laureys S. Effect of multichannel transcranial direct current stimulation to reduce hypertonia in individuals with prolonged disorders of consciousness: A randomized controlled pilot study. Ann Phys Rehabil Med 2019; 62:418-425. [DOI: 10.1016/j.rehab.2019.05.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 04/26/2019] [Accepted: 05/08/2019] [Indexed: 12/28/2022]
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17
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Management of Severely Brain-Injured Patients Recovering from Coma in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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18
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Can they Feel? The Capacity for Pain and Pleasure in Patients with Cognitive Motor Dissociation. NEUROETHICS-NETH 2018; 12:153-169. [PMID: 31983931 PMCID: PMC6951816 DOI: 10.1007/s12152-018-9361-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 03/27/2018] [Indexed: 01/18/2023]
Abstract
Unresponsive wakefulness syndrome is a disorder of consciousness wherein a patient is awake, but completely non-responsive at the bedside. However, research has shown that a minority of these patients remain aware, and can demonstrate their awareness via functional neuroimaging; these patients are referred to as having ‘cognitive motor dissociation’ (CMD). Unfortunately, we have little insight into the subjective experiences of these patients, making it difficult to determine how best to promote their well-being. In this paper, I argue that the capacity to experience pain or pleasure (sentience) is a key component of well-being for these patients. While patients with unresponsive wakefulness syndrome are believed to be incapable of experiencing pain or pleasure, I argue that there is evidence to support the notion that CMD patients likely can experience pain and pleasure. I analyze current neuroscientific research into the mechanisms of pain experience in patients with disorders of consciousness, and provide an explanation for why CMD patients likely can experience physical pain. I then do the same for physical pleasure. I conclude that providing these patients with pleasurable experiences, and avoiding subjecting them to pain, are viable means of promoting their well-being.
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19
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Pain assessment with the revised nociception coma scale and outcomes of patients with unresponsive wakefulness syndrome: results from a pilot study. Neurol Sci 2018; 39:1073-1077. [DOI: 10.1007/s10072-018-3330-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 03/16/2018] [Indexed: 01/31/2023]
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20
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Random support vector machine cluster analysis of resting-state fMRI in Alzheimer's disease. PLoS One 2018; 13:e0194479. [PMID: 29570705 PMCID: PMC5865739 DOI: 10.1371/journal.pone.0194479] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 03/05/2018] [Indexed: 12/19/2022] Open
Abstract
Early diagnosis is critical for individuals with Alzheimer's disease (AD) in clinical practice because its progress is irreversible. In the existing literature, support vector machine (SVM) has always been applied to distinguish between AD and healthy controls (HC) based on neuroimaging data. But previous studies have only used a single SVM to classify AD and HC, and the accuracy is not very high and generally less than 90%. The method of random support vector machine cluster was proposed to classify AD and HC in this paper. From the Alzheimer's Disease Neuroimaging Initiative database, the subjects including 25 AD individuals and 35 HC individuals were obtained. The classification accuracy could reach to 94.44% in the results. Furthermore, the method could also be used for feature selection and the accuracy could be maintained at the level of 94.44%. In addition, we could also find out abnormal brain regions (inferior frontal gyrus, superior frontal gyrus, precentral gyrus and cingulate cortex). It is worth noting that the proposed random support vector machine cluster could be a new insight to help the diagnosis of AD.
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21
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Naro A, Bramanti P, Bramanti A, Calabrò RS. Assessing pain in patients with chronic disorders of consciousness: Are we heading in the right direction? Conscious Cogn 2017; 55:148-155. [PMID: 28865377 DOI: 10.1016/j.concog.2017.08.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 08/16/2017] [Accepted: 08/18/2017] [Indexed: 01/03/2023]
Abstract
The deterioration of sensory-motor integration within the pain matrix in patients with chronic Disorders of Consciousness (DoC) is one of the principal mechanisms responsible for non-conscious pain perception. The present study aimed to assess whether the variability in the inter-peak interval (IPI) between the N2 and P2 components of laser evoked potentials (LEP) could represent an objective marker of the behavioral responsiveness to nociceptive stimulation, as measured by the Nociception Coma Scale-Revised (NCS-R), and regardless of the sensory part of pain processing. We found that only IPI variability showed a significant correlation with NCS-R score, independently of the stimulation intensity (that influences the sensory part of pain processing). It was thus concluded that IPI variability might represent an objective measure of pain processing, which may help clinicians in the development of effective pain management strategies.
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Affiliation(s)
- Antonino Naro
- IRCCS Centro Neurolesi "Bonino-Pulejo", Messina, Italy
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22
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Vink P, Lucas C, Maaskant JM, van Erp WS, Lindeboom R, Vermeulen H. Clinimetric properties of the Nociception Coma Scale (-Revised): A systematic review. Eur J Pain 2017; 21:1463-1474. [PMID: 28573825 PMCID: PMC5600098 DOI: 10.1002/ejp.1063] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2017] [Indexed: 11/12/2022]
Abstract
The Nociception Coma Scale is a nociception behaviour observation tool, developed specifically for patients with disorders of consciousness (DOC) due to (acquired) brain injury. Over the years, the clinimetric properties of the NCS and its revised version (NCS‐R) have been assessed, but no formal summary of these properties has been made. Therefore, we performed a systematic review on the clinimetric properties (i.e. reliability, validity, responsiveness and interpretability) of the NCS(‐R). We systematically searched CENTRAL, CINAHL, Embase, PsycInfo and Web of Science until August 2015. Two reviewers independently selected the clinimetric studies and extracted data with a structured form. Included studies were appraised on quality with the COSMIN checklist. Eight studies were found eligible and were appraised with the COSMIN checklist. Although nearly all studies lacked sample size calculation, and were executed by the same group of authors, the methodological quality ranged from fair to excellent. Important aspects of reliability, construct validity and responsiveness have been studied in depth and with sufficient methodological quality. The overview of clinimetric properties in this study shows that the NCS and NCS‐R are both valid and useful instruments to assess nociceptive behaviour in DOC patients. The studies provide guidance for the choice in NCS‐R cut‐off value for possible pain treatment and cautions awareness of interprofessional differences in NCS‐R measurements. Significance This systematic review provides a structured overview of the clinimetric properties of the Nociception Coma Scale (‐Revised) and provides insights for a solid evidence‐based nociception behaviour assessment and treatment plan.
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Affiliation(s)
- P Vink
- Department of Neurology and Neurosurgery, Academic Medical Center (AMC), Amsterdam, The Netherlands.,Omni Cura Nursing Teaching Research, Amsterdam, The Netherlands
| | - C Lucas
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Medical Faculty (AMC), University of Amsterdam, The Netherlands
| | - J M Maaskant
- Emma Children's Hospital, Academic Medical Center Amsterdam, The Netherlands.,ACHIEVE Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, The Netherlands
| | - W S van Erp
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, The Netherlands.,Coma Science Group, Cyclotron Research Center and Neurology Department, University of Liège, Belgium
| | - R Lindeboom
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Medical Faculty (AMC), University of Amsterdam, The Netherlands
| | - H Vermeulen
- Department of Surgery, Academic Medical Center (AMC), Amsterdam, The Netherlands.,Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ Healthcare), Nijmegen, The Netherlands
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23
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McGuire DB, Kaiser KS, Haisfield-Wolfe ME, Iyamu F. Pain Assessment in Noncommunicative Adult Palliative Care Patients. Nurs Clin North Am 2017; 51:397-431. [PMID: 27497016 DOI: 10.1016/j.cnur.2016.05.009] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Palliative care patients who have pain are often unable to self-report their pain, placing them at increased risk for underrecognized and undertreated pain. Use of appropriate pain assessment tools significantly enhances the likelihood of effective pain management and improved pain-related outcomes. This paper reviews selected tools and provides palliative care clinicians with a practical approach to selecting a pain assessment tool for noncommunicative adult patients.
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Affiliation(s)
- Deborah B McGuire
- Virginia Commonwealth University School of Nursing, 1100 East Leigh Street, PO Box 980567, Richmond, VA 23298, USA.
| | - Karen Snow Kaiser
- Clinical Quality and Safety, University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Mary Ellen Haisfield-Wolfe
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Florence Iyamu
- University of Maryland School of Nursing, 655 West Lombard Street, Baltimore, MD 21201, USA
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24
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Riganello F, Macrì S, Alleva E, Petrini C, Soddu A, Leòn-Carriòn J, Dolce G. Pain Perception in Unresponsive Wakefulness Syndrome May Challenge the Interruption of Artificial Nutrition and Hydration: Neuroethics in Action. Front Neurol 2016; 7:202. [PMID: 27899911 PMCID: PMC5110539 DOI: 10.3389/fneur.2016.00202] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 11/01/2016] [Indexed: 12/23/2022] Open
Affiliation(s)
| | - Simone Macrì
- Section of Behavioral Neuroscience, Department of Cell Biology and Neuroscience, Istituto Superiore di Sanità, Rome, Italy
| | - Enrico Alleva
- Section of Behavioral Neuroscience, Department of Cell Biology and Neuroscience, Istituto Superiore di Sanità, Rome, Italy
| | - Carlo Petrini
- Office of the President, Bioethics Unit, Istituto Superiore di Sanità, Rome, Italy
| | - Andrea Soddu
- Department of Physics and Astronomy, Brain and Mind Institute, The University of Western Ontario, London, ON, Canada
| | - Josè Leòn-Carriòn
- Human Neuropsychology Laboratory, Department of Experimental Psychology, School of Psychology, University of Seville, Seville, Spain
| | - Giuliano Dolce
- Research in Advanced Neurorehabilitation, Istituto S. Anna, Crotone, Italy
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25
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Schnakers C, Zasler N. Assessment and Management of Pain in Patients With Disorders of Consciousness. PM R 2016; 7:S270-S277. [PMID: 26568506 DOI: 10.1016/j.pmrj.2015.09.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 09/11/2015] [Accepted: 09/14/2015] [Indexed: 01/29/2023]
Abstract
Pain is a first-person experience that must be reported, verbally or nonverbally, to be correctly assessed. How, then, is pain perception determined in persons who are noncommunicative? This determination is a major clinical challenge because patients with disorders of consciousness are unable to communicate their feelings and possible pain experiences. This review will describe the current knowledge of evaluating pain perception in a minimally conscious state compared with an unconscious state (also known as vegetative state/unresponsive wakefulness syndrome) and how to approach the management of pain in these 2 populations.
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Affiliation(s)
- Caroline Schnakers
- Department of Neurosurgery, University of California-Los Angeles, 300 Stein Plaza, Wasserman Building #554D, Los Angeles, CA 90095-1563
| | - Nathan Zasler
- Concussion Care Centre of Virginia, Richmond, VA.,Tree of Life Services, Richmond, VA.,Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA.,Department of Physical Medicine and Rehabilitation, University of Virginia, Charlottesville, VA.,School of Health Sciences, Touro College, NY
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26
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Naro A, Leo A, Cannavò A, Buda A, Bramanti P, Calabrò RS. Do unresponsive wakefulness syndrome patients feel pain? Role of laser-evoked potential-induced gamma-band oscillations in detecting cortical pain processing. Neuroscience 2016; 317:141-8. [PMID: 26791527 DOI: 10.1016/j.neuroscience.2016.01.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 01/04/2016] [Accepted: 01/07/2016] [Indexed: 01/18/2023]
Affiliation(s)
- A Naro
- IRCCS Centro Neurolesi Bonino-Pulejo, Messina, Italy
| | - A Leo
- IRCCS Centro Neurolesi Bonino-Pulejo, Messina, Italy
| | - A Cannavò
- IRCCS Centro Neurolesi Bonino-Pulejo, Messina, Italy
| | - A Buda
- IRCCS Centro Neurolesi Bonino-Pulejo, Messina, Italy
| | - P Bramanti
- IRCCS Centro Neurolesi Bonino-Pulejo, Messina, Italy
| | - R S Calabrò
- IRCCS Centro Neurolesi Bonino-Pulejo, Messina, Italy.
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27
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Moving Toward Conscious Pain Processing Detection in Chronic Disorders of Consciousness: Anterior Cingulate Cortex Neuromodulation. THE JOURNAL OF PAIN 2015. [DOI: 10.1016/j.jpain.2015.06.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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28
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de Tommaso M, Navarro J, Lanzillotti C, Ricci K, Buonocunto F, Livrea P, Lancioni GE. Cortical responses to salient nociceptive and not nociceptive stimuli in vegetative and minimal conscious state. Front Hum Neurosci 2015; 9:17. [PMID: 25688200 PMCID: PMC4310288 DOI: 10.3389/fnhum.2015.00017] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 01/09/2015] [Indexed: 01/18/2023] Open
Abstract
Aims: Questions regarding perception of pain in non-communicating patients and the management of pain continue to raise controversy both at a clinical and ethical level. The aim of this study was to examine the cortical response to salient visual, acoustic, somatosensory electric non-nociceptive and nociceptive laser stimuli and their correlation with the clinical evaluation. Methods: Five Vegetative State (VS), 4 Minimally Conscious State (MCS) patients and 11 age- and sex-matched controls were examined. Evoked responses were obtained by 64 scalp electrodes, while delivering auditory, visual, non-noxious electrical and noxious laser stimulation, which were randomly presented every 10 s. Laser, somatosensory, auditory and visual evoked responses were identified as a negative-positive (N2-P2) vertex complex in the 500 ms post-stimulus time. We used Nociception Coma Scale-Revised (NCS-R) and Coma Recovery Scale (CRS-R) for clinical evaluation of pain perception and consciousness impairment. Results: The laser evoked potentials (LEPs) were recognizable in all cases. Only one MCS patient showed a reliable cortical response to all the employed stimulus modalities. One VS patient did not present cortical responses to any other stimulus modality. In the remaining participants, auditory, visual and electrical related potentials were inconstantly present. Significant N2 and P2 latency prolongation occurred in both VS and MCS patients. The presence of a reliable cortical response to auditory, visual and electric stimuli was able to correctly classify VS and MCS patients with 90% accuracy. Laser P2 and N2 amplitudes were not correlated with the CRS-R and NCS-R scores, while auditory and electric related potentials amplitude were associated with the motor response to pain and consciousness recovery. Discussion: pain arousal may be a primary function also in vegetative state patients while the relevance of other stimulus modalities may indicate the degree of cognitive and motor behavior recovery. This underlines the importance of considering the potential experience of pain also in patients in vegetative state and to appropriately assess a possible treatment also in those patients.
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Affiliation(s)
- Marina de Tommaso
- Basical Medical Science, Neuroscience and Sensory System (SMBNOS) Department, Bari Aldo Moro University Bari, Italy
| | - Jorge Navarro
- Fondazione San Raffaele-Presidio Ospedaliero di Riabilitazione ad Alta Specialità Brindisi, Italy
| | - Crocifissa Lanzillotti
- Fondazione San Raffaele-Presidio Ospedaliero di Riabilitazione ad Alta Specialità Brindisi, Italy
| | - Katia Ricci
- Basical Medical Science, Neuroscience and Sensory System (SMBNOS) Department, Bari Aldo Moro University Bari, Italy
| | - Francesca Buonocunto
- Fondazione San Raffaele-Presidio Ospedaliero di Riabilitazione ad Alta Specialità Brindisi, Italy
| | - Paolo Livrea
- Basical Medical Science, Neuroscience and Sensory System (SMBNOS) Department, Bari Aldo Moro University Bari, Italy
| | - Giulio E Lancioni
- Basical Medical Science, Neuroscience and Sensory System (SMBNOS) Department, Bari Aldo Moro University Bari, Italy
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29
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Mikell CB, Banks GP, Frey HP, Youngerman BE, Nelp TB, Karas PJ, Chan AK, Voss HU, Connolly ES, Claassen J. Frontal networks associated with command following after hemorrhagic stroke. Stroke 2014; 46:49-57. [PMID: 25492905 DOI: 10.1161/strokeaha.114.007645] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND PURPOSE Level of consciousness is frequently assessed by command-following ability in the clinical setting. However, it is unclear what brain circuits are needed to follow commands. We sought to determine what networks differentiate command following from noncommand following patients after hemorrhagic stroke. METHODS Structural MRI, resting-state functional MRI, and electroencephalography were performed on 25 awake and unresponsive patients with acute intracerebral and subarachnoid hemorrhage. Structural injury was assessed via volumetric T1-weighted MRI analysis. Functional connectivity differences were analyzed against a template of standard resting-state networks. The default mode network (DMN) and the task-positive network were investigated using seed-based functional connectivity. Networks were interrogated by pairwise coherence of electroencephalograph leads in regions of interest defined by functional MRI. RESULTS Functional imaging of unresponsive patients identified significant differences in 6 of 16 standard resting-state networks. Significant voxels were found in premotor cortex, dorsal anterior cingulate gyrus, and supplementary motor area. Direct interrogation of the DMN and task-positive network revealed loss of connectivity between the DMN and the orbitofrontal cortex and new connections between the task-positive network and DMN. Coherence between electrodes corresponding to right executive network and visual networks was also decreased in unresponsive patients. CONCLUSIONS Resting-state functional MRI and electroencephalography coherence data support a model in which multiple, chiefly frontal networks are required for command following. Loss of DMN anticorrelation with task-positive network may reflect a loss of inhibitory control of the DMN by motor-executive regions. Frontal networks should thus be a target for future investigations into the mechanism of responsiveness in the intensive care unit environment.
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Affiliation(s)
- Charles B Mikell
- From the Department of Neurological Surgery, Columbia University Medical Center, New York (C.B.M., G.P.B., B.E.Y., T.B.N., P.J.K., A.K.C., E.S.C.); Department of Radiology, Weill Cornell Medical College, Cornell University, New York (H.U.V.); and Division of Neurocritical Care, Department of Neurology, Columbia University Medical Center, New York (H.-P.F., J.C.).
| | - Garrett P Banks
- From the Department of Neurological Surgery, Columbia University Medical Center, New York (C.B.M., G.P.B., B.E.Y., T.B.N., P.J.K., A.K.C., E.S.C.); Department of Radiology, Weill Cornell Medical College, Cornell University, New York (H.U.V.); and Division of Neurocritical Care, Department of Neurology, Columbia University Medical Center, New York (H.-P.F., J.C.)
| | - Hans-Peter Frey
- From the Department of Neurological Surgery, Columbia University Medical Center, New York (C.B.M., G.P.B., B.E.Y., T.B.N., P.J.K., A.K.C., E.S.C.); Department of Radiology, Weill Cornell Medical College, Cornell University, New York (H.U.V.); and Division of Neurocritical Care, Department of Neurology, Columbia University Medical Center, New York (H.-P.F., J.C.)
| | - Brett E Youngerman
- From the Department of Neurological Surgery, Columbia University Medical Center, New York (C.B.M., G.P.B., B.E.Y., T.B.N., P.J.K., A.K.C., E.S.C.); Department of Radiology, Weill Cornell Medical College, Cornell University, New York (H.U.V.); and Division of Neurocritical Care, Department of Neurology, Columbia University Medical Center, New York (H.-P.F., J.C.)
| | - Taylor B Nelp
- From the Department of Neurological Surgery, Columbia University Medical Center, New York (C.B.M., G.P.B., B.E.Y., T.B.N., P.J.K., A.K.C., E.S.C.); Department of Radiology, Weill Cornell Medical College, Cornell University, New York (H.U.V.); and Division of Neurocritical Care, Department of Neurology, Columbia University Medical Center, New York (H.-P.F., J.C.)
| | - Patrick J Karas
- From the Department of Neurological Surgery, Columbia University Medical Center, New York (C.B.M., G.P.B., B.E.Y., T.B.N., P.J.K., A.K.C., E.S.C.); Department of Radiology, Weill Cornell Medical College, Cornell University, New York (H.U.V.); and Division of Neurocritical Care, Department of Neurology, Columbia University Medical Center, New York (H.-P.F., J.C.)
| | - Andrew K Chan
- From the Department of Neurological Surgery, Columbia University Medical Center, New York (C.B.M., G.P.B., B.E.Y., T.B.N., P.J.K., A.K.C., E.S.C.); Department of Radiology, Weill Cornell Medical College, Cornell University, New York (H.U.V.); and Division of Neurocritical Care, Department of Neurology, Columbia University Medical Center, New York (H.-P.F., J.C.)
| | - Henning U Voss
- From the Department of Neurological Surgery, Columbia University Medical Center, New York (C.B.M., G.P.B., B.E.Y., T.B.N., P.J.K., A.K.C., E.S.C.); Department of Radiology, Weill Cornell Medical College, Cornell University, New York (H.U.V.); and Division of Neurocritical Care, Department of Neurology, Columbia University Medical Center, New York (H.-P.F., J.C.)
| | - E Sander Connolly
- From the Department of Neurological Surgery, Columbia University Medical Center, New York (C.B.M., G.P.B., B.E.Y., T.B.N., P.J.K., A.K.C., E.S.C.); Department of Radiology, Weill Cornell Medical College, Cornell University, New York (H.U.V.); and Division of Neurocritical Care, Department of Neurology, Columbia University Medical Center, New York (H.-P.F., J.C.)
| | - Jan Claassen
- From the Department of Neurological Surgery, Columbia University Medical Center, New York (C.B.M., G.P.B., B.E.Y., T.B.N., P.J.K., A.K.C., E.S.C.); Department of Radiology, Weill Cornell Medical College, Cornell University, New York (H.U.V.); and Division of Neurocritical Care, Department of Neurology, Columbia University Medical Center, New York (H.-P.F., J.C.)
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30
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Abstract
Significant advances have been made in the behavioral assessment and clinical management of disorders of consciousness (DOC). In addition, functional neuroimaging paradigms are now available to help assess consciousness levels in this challenging patient population. The success of these neuroimaging approaches as diagnostic markers is, however, intrinsically linked to understanding the relationships between consciousness and the brain. In this context, a combined theoretical approach to neuroimaging studies is needed. The promise of such theoretically based markers is illustrated by recent findings that used a perturbational approach to assess the levels of consciousness. Further research on the contents of consciousness in DOC is also needed.
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Affiliation(s)
- Olivia Gosseries
- Coma Science Group, Cyclotron Research Center and Neurology Department, University of Liege, and University Hospital of Liege, 4000 Liege, Belgium; , , ,
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