The influence of the CRS-R score on functional outcome in patients with severe brain injury receiving early rehabilitation

Disorders of Consciousness

This article reviews the definition, assessment, neuroimaging, treatment, and rehabilitation for disorders of consciousness after an acquired brain injury. It also explores special considerations and new neuromodulation treatment options.

Knowledge, attitudes and practices of nurses regarding airway clearance in neurocritical illness patients: A cross-sectional study

AIM

We aimed to assess the level of knowledge, attitudes and practices regarding airway clearance among nurses and explore the factors affecting the knowledge, attitudes and practices.

DESIGN

A questionnaire-based cross-sectional study.

BACKGROUND

Airway clearance is an important method of eliminating excess secretions. In neuroscience nursing, nurses are important executors of airway management, and their knowledge, attitudes and practices can influence the effectiveness of airway clearance.

METHODS

This study was conducted from July to September 2023 in four hospitals in Jiangsu Province, China. A structured questionnaire about airway clearance was designed and used to collect the data. The nurses used this questionnaire to self-rate. The STROBE checklist for cross-sectional studies was followed.

RESULTS

The age, work experience, highest educational attainment and technical title of the nurses can significantly influence their knowledge. The age, highest educational attainment and technical title of the nurses can significantly impact their attitudes. Practice scores were significantly influenced by age, work experience, technical title, whether the nurses had received any training on airway clearance techniques, and whether the department developed procedures for implementing the airway clearance technology. Nurses' attitudes were significantly associated with knowledge and practice, and there was no significant correlation between knowledge and practice.

CONCLUSION

This study showed that age, work experience, highest educational attainment and training were related to knowledge, attitudes and practices. These findings suggest that nursing managers can conduct airway clearance training according to age group, working experience and education level of the nurses.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

IMPACT

The findings show that the level of knowledge, attitudes and practices related to airway clearance in neuroscience nursing among nurses were acceptable, which means that nurses can better perform airway management on patients. These findings serve as a significant reference for designing an airway clearance education for nurses and meet the needs of nurses in clinical nursing practice.

Predicting outcome in disorders of consciousness: A mega-analysis

OBJECTIVE

Assessing recovery potential in patients with disorders of consciousness (DoC) is pivotal for guiding clinical and ethical decisions. We conducted a mega-analysis of individual patient data to understand (1) if a time threshold exists, beyond which regaining consciousness is almost impossible, and (2) how recovery varies based on factors such as diagnosis, etiology, age, sex, and neuropsychological status.

METHODS

A systematic literature search revealed a total of 3290 patients. In this sample, we performed a Cox proportional hazards analysis for interval censored data.

RESULTS

We observed a late saturation of probability to regain consciousness in Kaplan-Meier curves, and the annual rate of recovery was remarkably stable, in that approximately 35% of patients regained consciousness per year. Patients in minimally conscious state (MCS) recovered more frequently than patients in unresponsive wakefulness syndrome (UWS). No significant difference was observed between the recovery dynamics of MCS subgroups: MCS+ and MCS-. Patients with hypoxic brain lesions showed worse recovery rate than patients with traumatic brain injury and patients with vascular brain lesions, while the latter two categories did not differ from each other. Male patients had moderately better chance to regain consciousness. While younger UWS patients recovered more frequently than older patients, it was not the case in MCS.

INTERPRETATION

Our findings highlight the necessity for neurologists to exercise caution when making negative predictions in individual cases, challenge traditional beliefs regarding recovery timelines, and underscore the importance of conducting detailed and prolonged assessments to better understand recovery prospects in DoC.

Short-term outcomes of early intensive neurorehabilitation for prolonged disorders of consciousness: A prospective cohort study

BACKGROUND

Advances in medical care have increased survival in people with severe brain injuries and with that the number of survivors with prolonged disorders of consciousness (PDOC) has increased. In the literature, early intensive neurorehabilitation (EIN) for people with PDOC is recommended to achieve the best possible outcomes.

OBJECTIVES

To evaluate the frequency and extent of recovery of consciousness, mortality, complications, pain and discomfort, and medication during a nationwide EIN programme in people with PDOC after acquired brain injury. We hypothesized that level of consciousness would improve in half of people with PDOC.

METHODS

Prospective cohort study. People with PDOC aged 16 years and older admitted to the EIN department centralized in a single rehabilitation centre in the Netherlands (Libra Rehabilitation & Audiology) were included. The EIN delivers a subacute medical level of care and rehabilitation for a maximum duration of 14 weeks. The outcome measures were level of consciousness (CRS-R), mortality, number of complications, medication and pain/discomfort (NCS-R).

RESULTS

Of the 104 people included, 68 % emerged to a minimal conscious state with command-following or higher during EIN and 44 % regained consciousness. Mortality during EIN was 6 %, and 50 % of deaths followed a non-treatment decision or withdrawal of life-sustaining treatment. Almost all participants had at least 1 medical complication, leading to hospital readmission for 30 %. 73 % showed no pain or discomfort. During EIN, cardiovascular medication and analgesics were reduced by 15 %.

CONCLUSIONS

During the EIN programme, a large percentage of people with PDOC regained at least a minimal conscious state or even consciousness. These outcomes and the frequent medical complications in these people suggest that intensive specialized care should be offered to all people with PDOC. The outcomes of this study might help health professionals to better inform the families of people with PDOC about the short-term prognosis of PDOC.

PROTOCOL REGISTRATION NUMBER

The Dutch Trial Register, NL 8138.

The Neurological Rehabilitation of Adults With Coma and Disorders of Consciousness

BACKGROUND

Severe quantitative disorders of consciousness (DoC) due to acute brain injury affect up to 47% of patients upon admission to intensive care and early rehabilitation units. Nevertheless, the rehabilitation of this vulnerable group of patients has not yet been addressed in any German-language guidelines and has only been studied in a small number of randomized clinical trials.

METHODS

In an S3 clinical practice guideline project, a systematic literature search was carried out for interventions that could improve consciousness in patients with coma, unresponsive wakefulness syndrome, or minimally conscious state after acute brain injury, and an evidence-based evaluation of these interventions was performed. Recommendations concerning diagnostic methods and medical ethics were issued by consensus.

RESULTS

Misdiagnoses are common in patients with DoC, with minimal consciousness often going unrecognized. Patients with DoC should, therefore, be repeatedly assessed with standardized instruments, particularly the Coma Recovery Scale-Revised. The literature search yielded 54 clinical trials, mostly of low quality; there were two randomized controlled clinical trials providing level 1 evidence. The best available evidence for the improvement of impaired consciousness is for the administration of amantadine (4 studies) and for anodal transcranial direct-current stimulation of the left dorsolateral prefrontal cortex in patients in the minimal conscious state (8 studies, 2 systematic reviews). Further important components of rehabilitation include positioning methods and sensory stimulation techniques such as music therapy.

CONCLUSION

For the first time, evidence-based German-language clinical practice guidelines have now become available for the neurological rehabilitation of patients with DoC.

Clinical application of recommendations for neurobehavioral assessment in disorders of consciousness: an interdisciplinary approach

Accurate diagnosis, prognosis, and subsequent rehabilitation care planning for persons with Disorders of Consciousness (DoC) has historically posed a challenge for neurological care professionals. Evidence suggests rates of misdiagnosis may be as high as 40% when informal beside evaluations are used to determine level of consciousness. The presence of myriad medical, neurological, functional (motor, sensory, cognitive) and environmental confounds germane to these conditions complicates behavioral assessment. Achieving diagnostic certainty is elusive but critical to inform care planning, clinical decision making, and prognostication. Standardized neurobehavioral rating scales has been shown to improve accuracy in distinguishing between coma, unresponsive wakefulness syndrome/vegetative state and minimally consciousness state as compared to informal assessment methods. Thus, these scales are currently recommended for use as the informal "gold standard" for diagnostic assessment in DoC. The following paper will present an evidence-based approach to neurobehavioral assessment for use in clinical practice. Strategies for optimizing assessment and aiding in identification and management of confounds that can limit diagnostic accuracy will be provided. Finally, clinical application of an interdisciplinary approach to identifying and managing confounds will be discussed and how assessment results can be used to identify trends in performance and guide prognostic counseling with families.

Evaluation of residual cognition in patients with disorders of consciousness based on functional near-infrared spectroscopy

SIGNIFICANCE

Accurate evaluation of consciousness in patients with prolonged disorders of consciousness (DOC) is critical for designing therapeutic plans, determining rehabilitative services, and predicting prognosis. Effective ways for detecting consciousness in patients with DOC are still needed.

AIM

Evaluation of the residual awareness in patients with DOC and investigation of the spatiotemporal differences in the hemodynamic responses between the minimally conscious state (MCS) and the unresponsive wakefulness syndrome (UWS) groups using active command-driven motor imagery (MI) tasks.

APPROACH

In this study, functional near-infrared spectroscopy (fNIRS) was used to measure the changes of hemodynamic responses in 19 patients with DOC (9 MCS and 10 UWS) using active command-driven MI tasks. The characteristics of the hemodynamic responses were extracted to compare the differences between the MCS and UWS groups. Moreover, the correlations between the hemodynamic responses and the clinical behavioral evaluations were also studied.

RESULTS

The results showed significant differences in the spatiotemporal distribution of the hemodynamic responses between the MCS and UWS groups. For the patients with MCS, significant increases in task-evoked hemodynamic responses occurred during the "YES" questions of the command-driven MI tasks. Importantly, these changes were significantly correlated with their coma-recovery scale-revised (CRS-R) scores. However, for the patients with UWS, no significant changes of the hemodynamic responses were found. Additionally, the results did not show any statistical correlation between the hemodynamic responses and their CRS-R scores.

CONCLUSIONS

The fNIRS-based command-driven MI tasks can be used as a promising tool for detecting residual awareness in patients with DOC. We hope that the findings and the active paradigm used in this study will provide useful insights into the diagnosis, therapy, and prognosis of this challenging patient population.

Machine learning and network analysis for diagnosis and prediction in disorders of consciousness

BACKGROUND

Prolonged Disorders of Consciousness (PDOC) resulting from severe acquired brain injury can lead to complex disabilities that make diagnosis challenging. The role of machine learning (ML) in diagnosing PDOC states and identifying intervention strategies is relatively under-explored, having focused on predicting mortality and poor outcome. This study aims to: (a) apply ML techniques to predict PDOC diagnostic states from variables obtained from two non-invasive neurobehavior assessment tools; and (b) apply network analysis for guiding possible intervention strategies.

METHODS

The Coma Recovery Scale-Revised (CRS-R) is a well-established tool for assessing patients with PDOC. More recently, music has been found to be a useful medium for assessment of coma patients, leading to the standardization of a music-based assessment of awareness: Music Therapy Assessment Tool for Awareness in Disorders of Consciousness (MATADOC). CRS-R and MATADOC data were collected from 74 PDOC patients aged 16-70 years at three specialist centers in the USA, UK and Ireland. The data were analyzed by three ML techniques (neural networks, decision trees and cluster analysis) as well as modelled through system-level network analysis.

RESULTS

PDOC diagnostic state can be predicted to a relatively high level of accuracy that sets a benchmark for future ML analysis using neurobehavioral data only. The outcomes of this study may also have implications for understanding the role of music therapy in interdisciplinary rehabilitation to help patients move from one coma state to another.

CONCLUSIONS

This study has shown how ML can derive rules for diagnosis of PDOC with data from two neurobehavioral tools without the need to harvest large clinical and imaging datasets. Network analysis using the measures obtained from these two non-invasive tools provides novel, system-level ways of interpreting possible transitions between PDOC states, leading to possible use in novel, next-generation decision-support systems for PDOC.

Redefining a minimal rehabilitation assessment protocol for severe acquired brain injuries

BACKGROUND

The assessment of patients with severe Acquired Brain Injury (sABI) is mandatory in every phase and setting of care, and requires a multidimensional and interdisciplinary approach, to develop the individual rehabilitation project, and monitor long-term functional outcomes. In 2001 the Italian Society of Physical and Rehabilitation Medicine (SIMFER) published the minimal assessment protocol for traumatic sABI, providing a comprehensive, standardized functional assessment based on the International Classification of Functioning, Disability and Health (ICF), 2001. In 2007, a new protocol was published, extended to all sABI patients (PMGCA). In 2019, the SIMFER appointed a working group to provide a revised, updated version: the PMGCA2020.

AIM

The purpose of this study was to describe the minimal assessment protocol to be applied at every stage and setting of the care process of patients with sABI.

METHODS

The working group, including one neurologist and 11 physiatrists experts in sABI rehabilitation, performed a review of the international recommendations for sABI assessment focusing on the following key words: "sABI assessment," "sABI rehabilitation," "sABI prognostic factors," "sABI rehabilitation assessment," "sABI outcome," in MEDLINE. Revision and integration proposals by each member were written and motivated, discussed and voted.

RESULTS

The PMGCA2020 is addressed to sABI adult patients. It investigates the main clinical problems of sABI at any time of the rehabilitation pathway. It includes a demographic/anamnestic section, a clinical/functional assessment section and an outcome measures section following the ICF model of functioning and the model of the construction of the rehabilitation project.

CONCLUSIONS

The PMGCA2020 provides an updated tool for the multidimensional rehabilitation assessment of sABI patients, at any stage of the rehabilitation pathway. Further studies will allow the validation of this minimum set of variables paving the way to an assessment standardization of patients with sABI in the rehabilitation settings.

CLINICAL REHABILITATION IMPACT

This minimum set of variables, defining patient's functioning and clinical status and outcomes, at every stage and setting of the care process to provide a framework for the standardization of the clinical evaluation of patients with sABI in rehabilitation settings.

Stimulation-related modifications of evolving functional brain networks in unresponsive wakefulness

Recent advances in neurophysiological brain network analysis have demonstrated novel potential for diagnosis and prognosis of disorders of consciousness. While most progress has been achieved on the population-sample level, time-economic and easy-to-apply personalized solutions are missing. This prospective controlled study combined EEG recordings, basal stimulation, and daily behavioral assessment as applied routinely during complex early rehabilitation treatment. We investigated global characteristics of EEG-derived evolving functional brain networks during the repeated (3–6 weeks apart) evaluation of brain dynamics at rest as well as during and after multisensory stimulation in ten patients who were diagnosed with an unresponsive wakefulness syndrome (UWS). The age-corrected average clustering coefficient C* allowed to discriminate between individual patients at first (three patients) and second assessment (all patients). Clinically, only two patients changed from UWS to minimally conscious state. Of note, most patients presented with significant changes of C* due to stimulations, along with treatment, and with an increasing temporal distance to injury. These changes tended towards the levels of nine healthy controls. Our approach allowed to monitor both, short-term effects of individual therapy sessions and possibly long-term recovery. Future studies will need to assess its full potential for disease monitoring and control of individualized treatment decisions.

Monitoring Eye Movements Depending on the Type of Visual Stimulus in Patients with Impaired Consciousness Due to Brain Damage

The eyeballs are often the only way to communicate messages as a result of brain damage. However, it is not uncommon for them to become dysfunctional, thus requiring the introduction of appropriate therapy. The trajectory of eye movements (saccadic movements and gaze fixation) during observation of a static and dynamic point presented with an eye tracker was analyzed in the present study. Twelve patients with brain injury of different etiology, with different degrees of consciousness disorders and not communicating through verbal and motor skills, qualified for the study. All participants demonstrated greater eye movement activity when presented with a dynamic task in which they observed a moving point. The findings suggest that effective eye movement therapy must incorporate dynamic stimuli.

Pulmonary infection in traumatic brain injury patients undergoing tracheostomy: predicators and nursing care

Background

Pulmonary infection is common yet serious complication in patients with severe traumatic brain injury (STBI). We aimed to evaluate the predicators of pulmonary infection in STBI patients undergoing tracheostomy, to provide evidence for the clinical nursing care of STBI patients.

Methods

This study was a retrospective cohort design. STBI patients undergoing tracheostomy treatment from January 1, 2019 to August 31, 2021 in our hospital were included. The characteristics of pulmonary infection and no pulmonary infection patients were analyzed.

Results

A total 216 STBI patients undergoing tracheostomy were included, the incidence of pulmonary infection was 26.85%. Diabetes (r = 0.782), hypoproteinemia (r = 0.804), duration of coma(r = 0.672), duration of mechanical ventilation(r = 0.724) and length of hospital stay (r = 0.655), length of hospital stay post tracheostomy (r = 0.554), mortality (r = 0.598) were all correlated with pulmonary infection (all p < 0.05). Klebsiella pneumoniae (33.87%) and Staphylococcus aureus (29.03%) were the most commonly seen pathogens in the pulmonary infection of TBI patients. Logistic regression analyses indicated that diabetes (OR 2.232, 95% CI 1.215–3.904), hypoproteinemia with plasma total protein < 60 g/L (OR 1.922, 95% CI 1.083–3.031), duration of coma ≥ 22 h (OR 2.864, 95% CI 1.344–5.012), duration of mechanical ventilation ≥ 5 days (OR 3.602, 95% CI 1.297–5.626), length of hospital stay ≥ 21 days (OR 2.048, 95% CI 1.022–3.859) were the risk factors of pulmonary infection in TBI patients undergoing tracheostomy (all p < 0.05).

Conclusions

Further investigations on the early preventions and treatments targeted on those risk factors are needed to reduce the pulmonary infection in clinical practice.

Efficacy of Transcranial Direct Current Stimulation Over Dorsolateral Prefrontal Cortex in Patients With Minimally Conscious State

Background

The treatment of patients in a minimally conscious state (MCS) remains challenging. Transcranial direct current stimulation (tDCS) is a non-invasive therapeutic method in treating neurologic diseases by regulating the cortical excitability. The aim is to investigate the effect of tDCS in patients with MCS in this study.

Methods

Eleven patients in MCS were enrolled in the study. All the patients received 5 daily sessions of 20-min sham tDCS, followed by 10 sessions of 20-min real tDCS. The anodal electrode and cathodal electrodes were placed over the left dorsolateral prefrontal cortex (DLPFC) and the right eyebrow, respectively. Assessment of Coma Recovery Scale-Revised (CRS-R) scores and resting-state functional MRI (rs-fMRI) scans was conducted three times in each patient: before tDCS (baseline, T0), post-sham tDCS at week 1 (T1), and post-real tDCS at week 2 (T2). The whole-brain functional connectivity (FC) was obtained by bilaterally computing FC from six seed regions: precuneus, middle frontal gyrus, supplemental motor area, angular gyrus, superior temporal gyrus, and occipital lobe. One-way repeated measure ANOVA was used to compare the differences of CRS-R scores and FC at T0, T1, and T2. The false discovery rate correction of p &lt; 0.001 was adopted for controlling multiple comparisons in FC analysis.

Results

Five patients with MCS showed obvious clinical improvement represented by increased CRS-R scores post- 2-week real tDCS. The CRS-R scores did not change post- 1-week sham treatment. No side effects were reported during the study. The FC of the bilateral supplementary motor area, right angular gyrus, and right superior temporal gyrus were significantly enhanced after 2-week real tDCS compared with that after 1-week sham-tDCS. In addition, FC of bilateral occipital lobe and right precuneus were significantly enhanced post- 2-week real tDCS compared with the baseline.

Conclusion

Our findings indicated that tDCS over DLPFC could serve as a potentially effective therapy for improving the consciousness state in patients with MCS. The FC in rs-fMRI can be modulated by tDCS at both the stimulation site (left DLPFC) and the distant regions.

One-year outcome of brain injured patients undergoing early neurological rehabilitation: a prospective observational study

Background

The present study intended to analyze the outcome of patients with severe brain injury one-year after discharge from early rehabilitation.

Methods

Early neurological rehabilitation patients admitted to intensive or intermediate care units and discharged between June 2018 and May 2020 were screened for eligibility. The level of consciousness was evaluated using the Coma Recovery Scale-Revised (CRS-R) upon admission and at discharge. At one-year follow-up, the outcome was assessed with the Glasgow Outcome Scale-extended (GOSE). Demographical and clinical data collected during inpatient rehabilitation were used to predict the outcome 1 year after discharge.

Results

Two hundred sixty-four patients (174 males, 90 females) with a median age of 62 years (IQR = 51–75) and a median duration of their disease of 18 days (IQR = 12–28) were included in the study. At follow-up, the mortality rate was 27% (n = 71). Age and discharge CRS-R total score were independent predictors in a Cox proportional hazards model with death (yes/no) as the dependent variable. According to the GOSE interviews, most patients were either dead (n = 71; 27%), in a vegetative state (n = 28; 11%) or had a severe disability (n = 124; 47%), whereas only a few patients showed a moderate disability (n = 18; 7%) or a good recovery (n = 23; 9%) 1 year after discharge. Age, non-traumatic etiology, discharge CRS-R total score and length of stay independently predicted whether the outcome was good or poor at follow-up.

Conclusion

Age was an important predictor for outcome at one-year follow-up, which might be due to altered brain plasticity and more comorbidities in elderly subjects. In addition, the present study demonstrated that the CRS-R total score at discharge might be more important for the prediction of one-year outcome than the initial assessment upon admission.