Ten-to-twelve years after specialized neurorehabilitation of young patients with severe disorders of consciousness: A follow-up study

Neurobehavioral Progress and Signs of Transition in Children With Prolonged Disorders of Consciousness: A Retrospective Longitudinal Study With the Coma Recovery Scale-Revised

BACKGROUND

Research on disorders of consciousness in children is scarce and includes disparate and barely comparable participants and assessment instruments and therefore provides inconclusive information on the clinical progress and recovery in this population. This study retrospectively investigated the neurobehavioral progress and the signs of transition between states of consciousness in a group of children admitted to a rehabilitation program either with an unresponsive wakefulness syndrome (UWS) or in a minimally conscious state (MCS).

METHODS

Systematic weekly assessments were conducted with the Coma Recovery Scale-Revised (CRS-R) until emergence from MCS, discharge, or death.

RESULTS

Twenty-one children, nine admitted with a UWS and 12 admitted in an MCS, were included in the study. Four children with a UWS transitioned to an MCS with a CRS-R of 10 (9.2 to 12.2) by showing visual pursuit, visual fixation, or localization to noxious stimulation. Twelve children emerged from the MCS with a CRS-R of 20.5 (19 to 21.7). Children who emerged from the MCS had had a shorter time postinjury and higher CRS-R at admission, compared with those who did not emerge.

CONCLUSIONS

Almost half of the children who were admitted with a UWS transitioned to an MCS, and almost all who were admitted in an MCS emerged from this state. Children who emerged had shorter times since injury and higher scores on the CRS-R at admission, compared with those who did not emerge.

Minimally conscious state plus versus minus: Likelihood of emergence and long-term functional independence

OBJECTIVE

Severe brain injuries can result in disorders of consciousness, such as the Minimally Conscious State (MCS), where individuals display intermittent yet discernible signs of conscious awareness. The varied levels of responsiveness and awareness observed in this state have spurred the progressive delineation of two subgroups within MCS, termed "plus" (MCS+) and "minus" (MCS-). However, the clinical validity of these classifications remains uncertain. This study aimed to investigate and compare the likelihood of emergence from MCS, as well as the functional independence after emergence, in individuals categorized as in MCS+ and MCS-.

METHODS

Demographic and behavioral data of 80 participants, admitted as either in MCS+ (n = 30) or MCS- (n = 50) to a long-term neurorehabilitation unit, were retrospectively analyzed. The neurobehavioral condition of each participant was evaluated weekly until discharge, demise, or emergence from MCS. The functional independence of those participants who emerged from MCS was assessed 6 months after emergence.

RESULTS

While only about half of the individuals classified as in MCS- (n = 24) emerged from the MCS, all those admitted as in MCS+ did, and in a shorter postinjury period. Despite these differences, all individuals who emerged from the MCS demonstrated similar high disability and low functional independence 6 months after emergence, regardless of their state at admission.

INTERPRETATION

Individuals classified as MCS+ exhibited a higher likelihood of emergence and a shorter time to emergence compared to those in MCS-. However, the level of functional independence 6 months after emergence was found to be unrelated to the initial state at admission.

Disorders of Consciousness in Children: Assessment, Treatment, and Prognosis

Children with acquired brain injury may experience prolonged disorders of consciousness (DoC); research on children with DoC lags behind adult literature. Rigorous evaluation of assessment tools used in children with DoC is lacking, though recent developments may contribute to improvements in care, particularly for assessment of young children and those without overt command following. Literature on prognosis continues to grow, reinforcing that early signs of consciousness suggest better long-term outcome. Although large clinical trials for children with DoC are lacking, single-site and multisite programmatic data inform standards of care and treatment options for children with DoC.

Head Control Contributes to Prediction of Emergence From the Minimally Conscious State in Children Admitted to Inpatient Rehabilitation

OBJECTIVE

To examine the utility of head and trunk control, assessed using the Physical Abilities and Mobility Scale, for predicting emergence from a minimally conscious state (eMCS) among children with acquired brain injury admitted to inpatient rehabilitation in a disorder of consciousness (DoC).

DESIGN

Retrospective study.

SETTING

Pediatric inpatient rehabilitation hospital.

PARTICIPANTS

Forty patients (2-21 years-old) directly admitted from acute care to pediatric inpatient brain injury rehabilitation in a DoC (average length of stay=85 days; N=40).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

State of consciousness (eMCS vs not) at discharge from inpatient rehabilitation.

RESULTS

Forty-five percent of patients emerged from a minimally conscious state during inpatient rehabilitation. Admission state of consciousness and head control (but not trunk control) were significantly associated with eMCS and provided complementary prognostic information. Admission state of consciousness (ie, admitting in a vegetative state/unresponsive wakefulness syndrome) afforded the greatest negative predictive value (93.8%), whereas admission head control ability afforded the greatest positive predictive value (81.8% for any independent head control; 100% for maintaining head-up position for >30 seconds). Fifty percent of patients who emerged during the inpatient stay did not have independent head control at admission, highlighting the importance of exploring head control as a prognostic marker in conjunction with indicators with greater sensitivity (eg, state of consciousness at admission).

CONCLUSIONS

A brief measure of head control at admission may contribute to identification of a subgroup of patients who are likely to emerge.

Exploring the measurement of pediatric cognitive-communication disorders in traumatic brain injury research: A scoping review

OBJECTIVE

To synthesize information about the constructs measured, measurement instruments used, and the timing of assessment of cognitive-communication disorders (CCDs) in pediatric traumatic brain injury (TBI) research.

METHODS AND PROCEDURES

Scoping review conducted in alignment with Arksey and O'Malley's five-stage methodological framework and reported per the PRISMA extension for Scoping Reviews. Inclusion criteria: (a) cohort description, case-control, and treatment studies; (b) participants with TBI aged 5-18 years; (c) communication or psychosocial outcomes; and (d) English full-text journal articles. The first author reviewed all titles, abstracts, and full-text articles; 10% were independently reviewed.

OUTCOMES AND RESULTS

Following screening, a total of 687 articles were included and 919 measurement instruments, measuring 2134 unique constructs, were extracted. The Child Behavior Checklist was the most used measurement instrument and 'Global Outcomes/Recovery' was the construct most frequently measured. The length of longitudinal monitoring ranged between ≤3 months and 16 years.

CONCLUSIONS AND IMPLICATIONS

We found considerable heterogeneity in the constructs measured, the measurement instruments used, and the timing of CCD assessment in pediatric TBI research. A consistent approach to measurement may support clinical decision-making and the efficient use of data beyond individual studies in systematic reviews and meta-analyses.

Brain Data in Pediatric Disorders of Consciousness: Special Considerations

SUMMARY

The diagnosis and management of disorders of consciousness in children continue to present a clinical, research, and ethical challenge. Though the practice guidelines for diagnosis and management of disorders of consciousness in adults are supported by decades of empirical and pragmatic evidence, similar guidelines for infants and children are lacking. The maturing conscious experience and the limited behavioral repertoire to report consciousness in this age group restrict extrapolation from the adult literature. Equally challenging is the process of heightened structural and functional neuroplasticity in the developing brain, which adds a layer of complexity to the investigation of the neural correlates of consciousness in infants and children. This review discusses the clinical assessment of pediatric disorders of consciousness and delineates the diagnostic and prognostic utility of neurophysiological and neuroimaging correlates of consciousness. The potential relevance of these correlates for the developing brain based on existing theoretical models of consciousness in adults is outlined.

Cognitive Recovery During Inpatient Rehabilitation Following Pediatric Traumatic Brain Injury: A Pediatric Brain Injury Consortium Study

OBJECTIVES

To characterize the demographics, clinical course, and predictors of cognitive recovery among children and young adults receiving inpatient rehabilitation following pediatric traumatic brain injury (TBI).

DESIGN

Retrospective observational, multicenter study.

SETTING

Eight acute pediatric inpatient rehabilitation facilities in the United States with specialized programs for treating patients with TBI.

PARTICIPANTS

Children and young adults (0-21 years) with TBI (n = 234) receiving inpatient rehabilitation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Admission and discharge status assessed by the WeeFIM Cognitive Developmental Functional Quotient (DFQ) and Cognitive and Linguistic Scale (CALS).

RESULTS

Patients admitted to pediatric inpatient rehabilitation are diverse in cognitive functioning. While the majority of patients make improvements, cognitive recovery is constrained for those admitted with the most severe cognitive impairments. Age, time since injury to rehabilitation admission, and admission WeeFIM Cognitive DFQ are significant predictors of cognitive functioning at discharge from inpatient rehabilitation.

CONCLUSIONS

This work establishes a multicenter Pediatric Brain Injury Consortium and characterized the demographics and clinical course of cognitive recovery during inpatient rehabilitation of pediatric patients with TBI to aid in prospective study design.

Behavioral signs of recovery from unresponsive wakefulness syndrome to emergence of minimally conscious state after severe brain injury

BACKGROUND

A precise description of behavioral signs denoting transition from an unresponsive wakefulness syndrome/vegetative state (UWS/VS) to minimally conscious state (MCS) or emergence from MCS after severe brain injury is crucial for prognostic purposes. A few studies have attempted this goal but involved non-standardized instruments, limited temporal accuracy or samples or focused on patients with (sub)acute condition.

OBJECTIVES

We aimed to describe the behavioral signs that led to a change in diagnosis as well as the factors affecting this transition in a large sample of patients with chronic disorders of consciousness after severe brain injury.

METHODS

In this retrospective cohort study, patients in UWS/VS or MCS were assessed with the Coma Recovery Scale Revised (CRS-R) at 5 times within the 2 weeks after their admission to a neurorehabilitation center and then weekly until emergence from MCS, discharge or death.

RESULTS

Of the 185 patients included, 33 in UWS/VS and 45 in MCS transitioned to another state. Transition to MCS was mostly denoted by one behavioral sign (71%), predominantly visual fixation, followed by localization to noxious stimulation, and visual pursuit, and could be predicted by etiology, time post-injury and age. Emergence from MCS was characterized by one sign in 64% of patients and by 2 signs (functional communication and objects use) in the remaining patients and could be predicted by time post-injury and number of behavioral signs at admission.

CONCLUSIONS

Transition from UWS to MCS was predominantly signalled by visual fixation and could be predicted by etiology, time post-injury and age. Emergence from MCS was mostly signalled by one sign and could be predicted by time post-injury and number of behavioral signs at admission. Clinicians should pay particular attention to visual and motor subscales of the CRS-R to detect behavioral recovery after severe brain injury. Database registration. ClinicalTrials.gov: NCT04687397.

Very Long-Term Outcomes in Children Admitted in a Disorder of Consciousness After Severe Traumatic Brain Injury

OBJECTIVES

To investigate functional outcomes and state of consciousness at 1 year and ≥2 years postinjury in children who sustained a traumatic brain injury and were in a disorder of consciousness (DOC), either vegetative state (VS) or minimally conscious state (MCS), upon admission to inpatient rehabilitation.

DESIGN

Retrospective chart review.

SETTING

Pediatric inpatient rehabilitation unit.

PARTICIPANTS

Children aged 2-18 years (N=37) who were admitted to inpatient rehabilitation with admission scores <30 on the Cognitive and Linguistic Scale (CALS).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Glasgow Outcome Scale- Extended, Pediatric Revision (GOS-E Peds), and state of consciousness based on previously established guidelines.

RESULTS

At admission, 16 children were in VS (43.2%) and 21 (56.8%) were in MCS. Children admitted in VS had a significantly longer time from injury to inpatient rehabilitation admission, lower CALS admission scores, were more likely to be in a DOC ≥28 days, and had greater disability at both follow-up time points. At the 1-year follow-up, 3 patients were in VS, 7 were in MCS, and 27 had emerged from MCS. By the time of the most recent follow-up (≥2y), 2 more patients had emerged from MCS. Across the cohort, GOS-E Peds scores at 1 year ranged from VS (GOS-E Peds, 7) to upper moderate disability (GOS-E Peds, 3). Most patients were functioning in the lower severe disability category (GOS-E Peds, 6) at 1 year (43.2%) and at the time of the most recent follow-up (43.2%). Twenty-seven patients (73.0%) showed stable GOS-E Peds scores between the 2 time points, 6 (16.2%) improved, and 4 (10.8%) were deceased.

CONCLUSIONS

Although a majority of patients emerged from a DOC by 1 year postinjury, most continued to demonstrate notable functional impairment at the 1-year follow-up that persisted to the most recent follow-up. A small subset demonstrated important improvements between 1 year and the most recent follow-up (2 patients emerged, 6 patients showed improvement in GOS-E Peds scores).

Outcome registry of early intensive neurorehabilitation in patients with disorders of consciousness: study protocol of a prospective cohort study

BACKGROUND

Prolonged disorders of consciousness (PDOC) may occur after severe brain injury. Two diagnostic entities are distinguished within PDOC: unresponsive wakefulness syndrome (UWS, previously known as vegetative state) and minimally conscious state (MCS). Patients with PDOC may benefit from early intensive neurorehabilitation (EIN). In the Netherlands, the EIN programme is provided by one designated expert rehabilitation centre and forms the starting point of a dedicated chain of specialised rehabilitation and care for this group. This study project, called DOCTOR: Disorders of Consciousness; Treatment and Outcomes Registry, sets up a registry and systematically investigates multiple short- and long-term outcomes of patients with PDOC who receive EIN.

METHODS

Single-centre prospective cohort study with a 2-year follow-up period. Patients with PDOC due to acute brain injury who receive EIN, aged 16 years and older are included. Measurements will take place at start EIN, in week 5, 10, and at discharge from the EIN programme (duration = max 14 weeks) and at week 28, 40, 52, and 104 after admission to the EIN programme, following patients through the health-care chain. Outcome measures are the changes over time in level of consciousness, using the Coma Recovery Scale-Revised; the frequency and type of medical complications; the mortality rate; level of disability, including the level of motor, cognitive, behavioural and emotional functioning; participation; and quality of life. Secondary outcomes include self-efficacy of caregivers, caregivers' strain and cost-effectiveness of the programme.

DISCUSSION

The DOCTOR study will provide insight in the recovery patterns and predictors of recovery for multiple outcomes in PDOC patients after following EIN. The results of the study will enable us to benchmark and improve EIN and the organisation of the health-care chain, both for patients with PDOC and for their families.

TRIAL REGISTRATION

Netherlands Trial Register, NL 8138 . Retrospectively registered 6 November 2019.

The multiplicity of caregiving burden: a qualitative analysis of families with prolonged disorders of consciousness

Objective: To understand the multiple and sometimes conflicting roles substitute decision makers (SDMs) of individuals in a vegetative state (VS), minimally conscious state (MCS), or with locked-in syndrome (LIS) perform while caring for a loved one and the competing priorities derived from these roles.Methods: We conducted semi-structured qualitative interviews using a constructive-grounded theory design. Twelve SDMs, who were also family members for 11 patients, were interviewed at two time points (except one) for a total of 21 in-depth interviews.Results: Participants described that caregiving is often the central role which they identify as their top priority and around which they coordinate and to some extent subordinate their other roles. In addition to caregiving, they participated in a wide variety of roles, which were sometimes in conflict, as they became caregivers for a loved one with chronic and complex needs. SDMs described the caregiver role as complex and intense that lead to physical, emotional, social, and economic burdens.Conclusion: SDMs report high levels of burdens in caring for a person with a prolonged disorder of consciousness. Lack of health system support that recognized the broader context of SDMs lives, including their multiple competing priorities, was a major contributing factor.

Interventions to improve outcomes in children and young people with unresponsive wakefulness syndrome following acquired brain injury: A systematic review

Unresponsive wakefulness syndrome (UWS) is a disorder of consciousness (DoC) which describes a state of wakefulness without evidence of self or environmental awareness, or interaction. There is currently no universally accepted evidence-based intervention for the treatment of UWS. This systematic review aimed to identify interventions to improve functioning in children and young people (0-25 years) with UWS following acquired brain injury (ABI). A systematic review of electronic databases was conducted, consisting of CINAHL, EMBASE, Medline, PsycINFO, PubMed, Cochrane Library, Scopus and Google Scholar. Eight studies met inclusion criteria. In these studies, the outcomes of interventions which aimed to improve quality of life, functional outcomes and/or increases in level of consciousness of paediatric patients in UWS were reported. Retrieved studies presented some evidence for improved consciousness and functional outcomes, following multi-component neurorehabilitation programmes, sensory stimulation or pharmacological interventions. Quality appraisal, using a modified version of the Downs and Black (1998) checklist, revealed risk of bias in a number of sources, including insufficient control over confounding variables, the use of inadequately validated outcome measures and concerns regarding diagnostic accuracy. More robust research is needed to adequately determine which interventions are most valuable at improving outcomes in paediatric UWS and to provide an improved evidence base for clinicians to draw upon when selecting treatment for patients.

Multidisciplinary attentive treatment for patients with chronic disorders of consciousness following severe traumatic brain injury in the NASVA of Japan

Primary Objective: The aim of this study was to demonstrate the clinical outcomes of long-term multidisciplinary attentive treatment (MAT) in patients with chronic disorders of consciousness (DOC) due to severe traumatic brain injury (TBI) following automotive accidents.Research Design: Five hundred and ten patients (mean age: 40.4 years) were enrolled in this retrospective study.Methods and Procedures: Patients were provided MAT for one to several years in the eight medical facilities of the National Agency for Automotive Safety and Victims' Aid (NASVA) in Japan. Clinical status for consciousness, communication, and activities of daily living were evaluated using the NASVA grading system.Outcomes and results: Following MAT, NASVA scores at discharge were significantly improved compared to those at admission in every patient subgroup including sex, age, NASVA score, and association with/without hypoxic encephalopathy at admission. Younger age, shorter interval between injury and admission, and better neurocognitive function at admission were found to be significant and independent factors for a good prognosis.Conclusions: MAT can partially improve the cognitive and physical abilities of patients with chronic DOC. From the perspective of not only restoring a patient's daily life, but also reducing the caregiver's burden, this type of treatment program warrants more public attention.

International survey on diagnostic and prognostic procedures in pediatric disorders of consciousness

AIMS

1. to investigate diagnostic and prognostic procedures routinely used by international professionals to assess children with disorders of consciousness (DoC); 2. to explore use and availability of internal and national guidelines for pediatric DoC; 3. to identify international differences in diagnostic/prognostic protocols.

METHODS

The International Brain Injury Association DoC Special Interest Group emailed a survey link to 43,469 professionals. The survey included questions on diagnostic/prognostic procedures and guidelines for children with DoC.

RESULTS

Data on 82 respondents [(50% physicians) primarily from Europe (43.9%)and North America (37.8%)] were analyzed. Common diagnostic tools included the Glasgow Coma Scale for clinical assessment (94%), the Coma Recovery Scale-Revised for outcome measurement (57%), and cerebral MRI (94%). Clinical features used most frequently to inform prognosis varied with patient age. Few respondents used national (28%) admission protocols for children with DoC, and most were unaware of published national guidelines for diagnostic (72%) and prognostic (85%) procedures. Compared to North American respondents, more European respondents were physicians and used neurophysiological data for prognosis.

CONCLUSIONS

This international survey provides useful information about diagnostic and prognostic procedures currently used for children with DoC and highlights the need for guidelines to promote best practices for diagnosis/prognosis in pediatric DoC.

Evidence-based position paper on Physical and Rehabilitation Medicine professional practice for Adults with Acquired Brain Injury. The European PRM position (UEMS PRM Section)

BACKGROUND

Acquired brain injury (ABI) is damage to the brain that occurs after birth caused either by a traumatic or by a nontraumatic injury. The rehabilitation process following ABI should be performed by a multi-professional team, working in an interdisciplinary way, with the aim of organizing a comprehensive and holistic approach to persons with every severity of ABI. This Evidence Based Position Paper represents the official position of the European Union through the UEMS Physical and Rehabilitation Medicine (PRM) Section and designates the professional role of PRM physicians for people with ABI. The aim was to formulate recommendations on the PRM physician's professional practice for persons with ABI in order to promote their functioning and enhance quality of life.

METHODS

This paper has been developed according to the methodology defined by the Professional Practice Committee of the UEMS-PRM Section: a systematic literature search has been performed in PubMed and Core Clinical Journals. On the basis of the selected papers, recommendations have been made as a result of five Delphi rounds.

RESULTS

The literature review as well as thirty-one recommendations are presented.

CONCLUSIONS

The expert consensus is that structured, comprehensive and holistic rehabilitation program delivered by the multi-professional team, working in an interdisciplinary way, with the leadership and coordination of the PRM physician, is likely to be effective, especially for those with severe disability after brain injury.

Are visual functions diagnostic signs of the minimally conscious state? an integrative review

Visual pursuit (VP) and visual fixation (VF) have been recognized as the first signs of emerging consciousness and, therefore, are considered indicative of the minimally conscious state (MCS). However, debate exists about their status as they are considered either conscious reactions or reflexes. The aim of this study is to review the evidence of the definition, operationalization, and assessment of VP and VF in unconscious patients. PubMed and EMBASE were searched for relevant papers between May 26, 1994 and October 1, 2016. In addition, an internet search was done to identify other relevant papers, reports and manuals of assessment methods. Papers were included if the definition, operationalization, or assessment method of VP and VF was discussed in patients with disorders of consciousness. We identified 2364 articles, of which 38 were included. No uniform definitions of VP and VF were found. VP and VF were operationalized differently, depending on which scale was used. The Coma Recovery Scale-revised and the Sensory Tool to Assess Responsiveness were the only diagnostic scales found; the other scales were developed to monitor DOC patients. The use of a mirror was the most sensitive method for detecting VP and VF. The literature about the importance VP and VF in relation with consciousness is controversial. This integrative review shows a lack of consensus regarding the definition, operationalization, and assessment of VP and VF. International consensus development about the definition, operationalization, and assessment of VP and VF is recommended.

Task-free spectral EEG dynamics track and predict patient recovery from severe acquired brain injury

For some patients, coma is followed by a state of unresponsiveness, while other patients develop signs of awareness. In practice, detecting signs of awareness may be hindered by possible impairments in the patient's motoric, sensory, or cognitive abilities, resulting in a substantial proportion of misdiagnosed disorders of consciousness. Task-free paradigms that are independent of the patient's sensorimotor and neurocognitive abilities may offer a solution to this challenge. A limitation of previous research is that the large majority of studies on the pathophysiological processes underlying disorders of consciousness have been conducted using cross-sectional designs. Here, we present a study in which we acquired a total of 74 longitudinal task-free EEG measurements from 16 patients (aged 6–22 years, 12 male) suffering from severe acquired brain injury, and an additional 16 age- and education-matched control participants. We examined changes in amplitude and connectivity metrics of oscillatory brain activity within patients across their recovery. Moreover, we applied multi-class linear discriminant analysis to assess the potential diagnostic and prognostic utility of amplitude and connectivity metrics at the individual-patient level. We found that over the course of their recovery, patients exhibited nonlinear frequency band-specific changes in spectral amplitude and connectivity metrics, changes that aligned well with the metrics' frequency band-specific diagnostic value. Strikingly, connectivity during a single task-free EEG measurement predicted the level of patient recovery approximately 3 months later with 75% accuracy. Our findings show that spectral amplitude and connectivity track patient recovery in a longitudinal fashion, and these metrics are robust pathophysiological markers that can be used for the automated diagnosis and prognosis of disorders of consciousness. These metrics can be acquired inexpensively at bedside, and are fully independent of the patient's neurocognitive abilities. Lastly, our findings tentatively suggest that the relative preservation of thalamo-cortico-thalamic interactions may predict the later reemergence of awareness, and could thus shed new light on the pathophysiological processes that underlie disorders of consciousness.

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Using behavioral criteria, disorders of consciousness are often misdiagnosed

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We probed the diagnostic and prognostic value of task-free spectral EEG metrics

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Metrics changed non-linearly across recovery and predicted level of consciousness

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EEG connectivity predicted the level of patient recovery with 75% accuracy

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These metrics are fully independent of the patient's neurocognitive abilities