Specialized Early Treatment for Persons With Disorders of Consciousness: Program Components and Outcomes.

Specialized Early Treatment for Persons with Disorders of Consciousness: Program Components and Outcomes.

Arch Phys Med Rehabil. 2013 May 31;
Seel RT, Douglas J, Dennison AC, Heaner S, Farris K, Rogers C

OBJECTIVE: To describe a specialized early treatment program for persons with disorders of consciousness (DOC) that includes family education; to identify rates of secondary conditions, imaging used and selected interventions; and to evaluate outcomes. DESIGN: A single center, retrospective, pre-post design using electronic medical record data. SETTING: A CARF-accredited, long-term acute care hospital that provides acute medical and inpatient rehabilitation levels of care for people with catastrophic injuries. PARTICIPANTS: 210 persons aged 14 to 69 with DOC of primarily traumatic etiology admitted at a mean of 41.0 (SD=27.2) days post-injury; 2% were in coma, 41% were in the vegetative state and 57% were in the minimally conscious state. INTERVENTIONS: An acute medical level of care with 90+ minutes of daily interdisciplinary rehabilitation and didactic and hands-on caretaking education for families. MAIN OUTCOME MEASURES: Coma Recovery Scale-Revised, Modified Ashworth Scale, and discharge disposition. RESULTS: Program admission medical acuity included dysautonomia – 15%, airway modifications – 79%, infections (e.g., pneumonia – 16%, urinary tract infection – 14%, and blood – 11%), deep vein thrombosis – 17%, pressure ulcers – 14%, and marked hypertonia – 30% in each limb. There were 168 program interruptions (i.e., 139 surgeries, 29 non-surgical intensive care unit transfers). Mean length of stay was 39.1±29.4 (range 6-204 days). Patients showed improved consciousness and respiratory function and reduced pressure ulcers and upper extremity hypertonia. At discharge, 54% showed sufficient emergence to transition to mainstream inpatient rehabilitation and 29% did not emerge but were discharged home to family with on-going programmatic support; only 13% did not emerge and were institutionalized. CONCLUSIONS: Persons with DOC due primarily to traumatic etiology who receive specialized early treatment that includes acute medical care and 90+ minutes of daily rehabilitation are likely to show improved consciousness and body function; more than half may transition to mainstream inpatient rehabilitation. Families who receive comprehensive education and hands on training with on-going follow-up support may be twice as likely to provide care for medically stable persons with DOC in their homes v. nursing facility placement. HubMed – rehab


Rationale and design of the prospective German registry of outcome in patients with severe disorders of consciousness following acute brain injury (KOPF-R).

Arch Phys Med Rehabil. 2013 May 31;
Eva G, Anke-Maria K, Kaitlen H, Marion A, Lydia B, Jürgen H, Ralf J, Eberhardt K, Ulrich M, Friedemann M, Thomas M, Dennis N, Matthias S, Andreas S, Andreas B

OBJECTIVE: To describe rationale and design of a new patient registry (KOPF-R, Koma Outcome von Patienten der Frührehabilitation) which has the scope to examine determinants of long-term outcome and functioning of patients with severe disorders of consciousness (DOC) . DESIGN: Prospective multicenter neurological rehabilitation registry SETTING: Five specialized neurological rehabilitation facilities PARTICIPANTS: Patients with DOC in vegetative state (VS) or minimally conscious state (MCS) as defined by the coma recovery scale-revised (CRS-R) following brain injury INTERVENTIONS: n/a MAIN OUTCOME MEASURES: Coma Recovery Scale-Revised (CRS-R), Functional Independence Measure (FIM), emergence from MCS RESULTS: The registry was set up in five facilities across the state of Bavaria/Germany with a special expertise in the rehabilitation of acquired brain injury. Inclusion of patients started in August 2011. Measures include sociodemographic and clinical characteristics, course of acute therapy, electrophysiological measures (evoked potentials, electroencephalogram, EEG), neuron specific enolase (NSE), current medication, functioning, cognition, participation, quality of life, quantity and characteristics of rehabilitation therapy, caregiver burden, and attitudes towards end-of-life decisions. By end of January 2012, 42 patients (38% female) with a mean age of 57 years (standard deviation SD 16) were enrolled. Main diagnoses were traumatic brain injury (TBI, 24%), intracerebral or subarachnoid hemorrhage (IAH/SAH, 31%), and anoxic-ischemic encephalopathy (AIE, 45%). Mean CRS-R score at admission to rehabilitation was 5.9 (SD 3.3), mean FIM score at admission was 18 (SD 0.4). CONCLUSIONS: The KOPF-registry aspires to contribute prospective data on prognosis in severe DOC. HubMed – rehab


Functional Outcomes in Traumatic Disorders of Consciousness: 5-Year Outcomes from the NIDRR Traumatic Brain Injury Model Systems.

Arch Phys Med Rehabil. 2013 May 31;
Whyte J, Nakase-Richardson R, Hammond FM, McNamee S, Giacino JT, Kalmar K, Greenwald B, Yablon SA, Horn LJ

OBJECTIVE: To characterize the 5-year outcomes of patients with traumatic brain injury (TBI) not following commands when admitted to acute inpatient rehabilitation. DESIGN: Retrospective analysis of prospectively-collected data from the NIDRR-funded Traumatic Brain Injury Model System (TBIMS). SETTING: Inpatient rehabilitation hospitals participating in the TBIMS program. PARTICIPANTS: One hundred eight (108) patients with TBI not following commands at admission to acute inpatient rehabilitation were divided into 2 groups (early recovery: followed commands prior to discharge; n = 72; late recovery: did not follow commands prior to discharge; n = 36). INTERVENTIONS: N/A MAIN OUTCOME MEASURES: Functional Independence Measure items. RESULTS: For the early recovery group, depending on the FIM item, 8% – 21% of patients were functioning independently at discharge, increasing to 56% to 85% by 5-years post-injury. The proportion functioning independently increased from discharge to 1 year, 1 to 2 years and 2 – 5 years. In the late recovery group, depending on the FIM item, 19 – 36% of patients were functioning independently. The proportion of independent patients increased significantly from discharge to 1 year and from 1 to 2 years, but not from 2 to 5 years. CONCLUSIONS: Substantial proportions of patients admitted to acute inpatient rehabilitation prior to following commands recover independent functioning over as long as 5 years, particularly if they begin to follow commands prior to hospital discharge. HubMed – rehab