Recovery Profiles of Cognitive-Sensory Modalities in Patients in the Minimally Conscious State Following Traumatic Brain Injury

Validating the Western Neuro Sensory Stimulation Profile for patients with severe traumatic brain injury who are slow-to-recover

BACKGROUND/AIM

The Western Neuro Sensory Stimulation Profile (WNSSP) is designed to measure disorders of consciousness in people with severe traumatic brain injury who are slow-to-recover. This study explores internal consistency reliability and concurrent validity of the WNSSP with function and two other consciousness measures.

METHOD

Retrospective chart audit of all severe traumatic brain injury patients admitted to a specialist neurological rehabilitation centre from January 2001 to December 2006 in a vegetative or minimally conscious state. Medical record of demographical, clinical and Glasgow Coma Scale (GCS) data were recorded. To be included in the study, patients needed admission and discharge WNSSP results; plus Functional Independence Measure™ (FIM™) and Rancho Los Amigos Scale (RLAS) scores.

RESULTS

Of 37 potential participants, 33 had required WNSSP results (mean age 28 years; 27 male participants). Internal consistency reliability was very high (α = 0.933). Concurrent validity in relation to function was significant but weak at admission for FIM™ Total-scale but not subscales (rs  = -0.146, P = 0.0424). At discharge, there was a modest relationship with FIM™ Motor-subscale (rs  = 0.374; P = 0.045), and FIM™ Cognition-subscale (rs  = 0.412; P = 0.026) scores, but not the FIM™ Total-scale. Concurrent validity in relation to the RLAS was strong at admission (rs  = 0.693, P = 0.01) and discharge (rs  = 0.788, P = 0.01). The WNSSP and GCS scores were not associated.

CONCLUSION

The WNSSP is sensitive to behavioural change in slow-to-recover patients with severe traumatic brain injury. It demonstrates very high internal consistency reliability, and positive evidence of concurrent validity with FIM™ and the RLAS providing detailed description of cognitive-sensory behaviour within RLAS-levels.

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

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

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

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

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

Sequence of recovery during the course of emergence from the minimally conscious state

OBJECTIVE

To document and examine recovery profiles of persons during the course of emergence from a minimally conscious state (MCS) after traumatic brain injury (TBI).

DESIGN

Case series.

SETTING

Participants in an inpatient brain injury rehabilitation program.

PARTICIPANTS

Nine people with TBI who emerged from MCS.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

The Western Neuro Sensory Stimulation Profile.

RESULTS

In all cases, stereotyped (nonreflexive) movement was the first behavior to resolve, yet by itself it was never sufficient to indicate emergence from the MCS. Two of the 9 patients showed consistent object manipulation before all 3 elements of functional communication. Conversely, in 2 patients, all 3 components of functional communication emerged before object manipulation. In the remaining 5 patients, object manipulation occurred along with components of functional communication.

CONCLUSIONS

During the course of data collection, issues were raised about differentiation between the MCS and posttraumatic amnesia. The data are also discussed within the context of the work of Giacino et al and the development of their scale to measure duration of the MCS. These data support the theory that functional communication and object manipulation are the 2 key indicators of emergence from MCS.

The minimally conscious state and recovery potential: a follow-up study 2 to 5 years after traumatic brain injury

OBJECTIVE

To document recovery in persons who were in the minimally conscious state (MCS) for at least 1 month after traumatic brain injury (TBI).

DESIGN

Patient series.

SETTING

Participants who had been discharged from an inpatient rehabilitation unit.

PARTICIPANTS

Eighteen people with TBI and their relatives.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Western Neuro Sensory Stimulation Profile, Disability Rating Scale (DRS), FIM instrument, Dementia Rating Scale, and Sydney Psychosocial Reintegration Scale (SPRS).

RESULTS

Level of functioning at follow-up varied from extremely severe disability or greater on the DRS (n=4) to mild disability (n=1). These outcomes were corroborated by results of the FIM and the Dementia Rating Scale. All participants experienced some (44%) or major (56%) change in their level of psychosocial functioning on the SPRS compared with their preinjury level. There were no significant correlations between duration of time in the MCS and outcome on FIM, DRS, or SPRS.

CONCLUSIONS

These results highlight the heterogeneity of outcome even after a prolonged duration of MCS after TBI. A large proportion of the patients was functionally independent in basic daily activities, although all experienced residual impairments and disabilities. The low correlation coefficients between duration of MCS and the outcome measures suggest that prognostic statements based on length of time a person is in the MCS cannot be made with confidence.