Symptomatic treatment of unresponsive wakefulness syndrome with transcranially focused extracorporeal shock waves.

OBJECTIVE: Can stimulation of nerve growth factors by focused transcranial extracorporeal shock wave therapy (TESWT) be made effective for persons within unresponsive wakefulness syndrome (apallic syndrome)? DESIGN: Between eight and 18 years after the brain lesion, five patients with unresponsive wakefulness syndrome of differing severity received TESWT with the device Duolith (Storz Medical) during four-week physicomedical complex therapies. In the previous years they had been treated with the same complex therapies without TESWT. The vigilance did not change. RESULTS: After two-four years and an average of 5.2 treatment series, the patients' abilities improved by 135.9% on the German Coma Remission Scale (KRS) and by 43.6% on the Glasgow Coma Scale. In the motor area of the KRS, the patients improved by 64.3%. Three PEG feeding tubes could be removed, nonverbal communication initiated four times. CONCLUSION: In this longitudinal observation study, focused TESWT stimulated vigilance in patients with unresponsive wakefulness syndrome. The precise neurophysiological effects remain to be verified by a study of the clinical results.

Rehabilitation outcome of anoxic-ischaemic encephalopathy survivors with prolonged disorders of consciousness.

OBJECTIVES: To examine the natural clinical course of patients admitted to inpatient neurorehabilitation in a coma, vegetative state (VS), or minimally conscious state (MCS) after anoxic-ischaemic encephalopathy (AIE). METHODS: This is a retrospective cohort study of 113 consecutive patients admitted to a German inpatient neurorehabilitation centre with severe disorders of consciousness (DOC) following AIE due to cardiac arrest over a 6-year period. Functional independence was measured with the Glasgow Outcome Scale (GOS) and recovery of consciousness with the Coma Remission Scale (CRS). Separate binary logistic regression models were used to identify independent predictors for functional and behavioural outcomes. RESULTS: Seven patients (6.2%) achieved a good functional outcome (GOS 4-5). Five of these showed significant functional improvement within the first 8 weeks. 22 patients (19.5%) recovered consciousness; the last patient began to make significant improvement between weeks 10 and 12. Logistic regression showed that both increasing age and lower admission CRS predicted unfavourable functional outcome and persistent DOC. A longer stay in the ICU also predicted persistent DOC at the end of neurorehabilitation. However, neither malignant somatosensory evoked potential (SEP) test results nor hypothermia treatment on the ICU were outcome predictors in either outcome category. CONCLUSION: Even among severely affected AIE patients arriving at a neurological rehabilitation centre in a DOC, there remains potential for functional and behavioural improvement. However, significant improvements may not begin for up to 3 months post-injury. This study suggests that recovery of consciousness and even a good neurological outcome are possible despite malignant SEP test results.

Long-lasting functional disabilities in patients who recover from coma after cardiac operations.

BACKGROUND: Uncertainty regarding the long-term functional outcome of patients who awaken from coma after cardiac operations is difficult for families and physicians and may delay rehabilitation. We studied the long-term functional status of these patients to determine if duration of coma predicted outcome. METHODS: We followed 71 patients who underwent cardiac operations; recovered their ability to respond to verbal commands after coma associated with postoperative stroke, encephalopathy, and/or seizures; and were discharged from the hospital. The Glasgow Outcome Scale Extended (GOSE) was used to assess functional disability 2 to 4 years after discharge. Outcomes were classified as favorable (GOSE scores 7 and 8) and unfavorable (GOSE scores 1-6). RESULTS: Of 71 patients identified, 39 were interviewed, 15 died, 1 refused to be interviewed, and 16 were lost to follow-up. Of the 54 patients with completed GOSE evaluations, only 15 (28%) had favorable outcomes. Among patients with unfavorable outcomes, 15 (28%) died, 14 (26%) survived with moderate disabilities, and 10 (18%) had severe disabilities. Factors associated with unfavorable outcomes were increases in duration of coma (p = 0.007), time in intensive care (p = 0.006), length of hospitalization (p = 0.004), and postoperative serum creatine kinase levels (p = 0.006). Only duration of coma was an independent predictor of unfavorable outcome (odds ratio [OR], 1.25; 95% confidence interval [CI], 1.008-1.537; p = 0.042). Patients with durations of coma greater than 4 days were more likely to have unfavorable outcomes (OR, 5.1; 95% CI, 1.3-21.3; p = 0.02). CONCLUSIONS: Two thirds of comatose patients who survived to discharge after cardiac operations had unfavorable long-term functional outcomes. A longer duration of unconsciousness is a predictor of unfavorable outcome.

Post-coma persons with extensive multiple disabilities use microswitch technology to access selected stimulus events or operate a radio device.

The present two studies extended research evidence on the use of microswitch technology by post-coma persons with multiple disabilities. Specifically, Study I examined whether three adults with a diagnosis of minimally conscious state and multiple disabilities could use microswitches as tools to access brief, selected stimulus events. Study II assessed whether an adult, who had emerged from a minimally conscious state but was affected by multiple disabilities, could manage the use of a radio device via a microswitch-aided program. Results showed that the participants of Study I had a significant increase of microswitch responding during the intervention phases. The participant of Study II learned to change radio stations and seemed to spend different amounts of session time on the different stations available (suggesting preferences among the programs characterizing them). The importance of microswitch technology for assisting post-coma persons with multiple disabilities to positively engage with their environment was discussed.

Estimulação multissensorial em pacientes comatosos: uma revisão da literatura / Estímulo multi-sensorial en pacientes comatosos: encuesta sobre la literatura / Multisensorial stimulation in comatose patients: a literature survey

O estado de coma é uma situação que se caracteriza pelo extremo rebaixamento do nível de consciência, em que o indivíduo permanece com os olhos fechados, sem percepção alguma do meio externo, incapaz de se comunicar, responder a comandos e emitir comportamentos elaborados. O nível de consciência, ou seja, o estado de alerta comportamental que nos mantém despertos, depende do Sistema Ativador Reticular Ascendente (SARA), que é localizado na região pontomesencefálica do tronco encefálico. O coma pode ser gerado por diversas etiologias, causando prejuízos na ação de ativação cortical desempenhada pelo Sistema Ativador Reticular Ascendente. Com intuito de facilitar a recuperação do estado de coma, foram criados programas de estimulação multissensorial, visando a estimular o Sistema Ativador Reticular Ascendente e, assim, auxiliar na recuperação do nível de consciência de pacientes comatosos. Desta forma, o objetivo deste trabalho foi analisar o que a literatura mostra sobre a influência da estimulação multissensorial sobre o nível de consciência de pacientes em estado de coma. Foi realizada uma revisão de literatura nas bases de dados eletrônicos Medline, Cochrane, Scielo e Lilacs, nos sites de pesquisas Pubmed e Highwire. Foram selecionados artigos científicos de 1983 a 2007. Os descritores utilizados foram: coma, estimulação sensorial, percepção e reabilitação. Foram incluídos ensaios clínicos enfocando a estimulação multissensorial em pacientes comatosos, e foram excluídos artigos que estudaram outras formas de tratamento realizadas em pacientes em coma que não objetivaram o aumento do nível de consciência. Foram analisados vinte artigos científicos que apresentaram resultados controversos em relação ao tipo de estimulação, tempo de duração da terapia e resultados alcançados após a aplicação do programa de estimulação multissensorial em comatosos. Apesar de indícios clínicos apontarem melhora no nível de consciência com a utilização da...

A coma is a situation of extreme degradation of the level of consciousness where the individual remains with closed eyes, with no perception of the external world, incapable of communicating, answering to commands and having elaborated behaviors. The level of consciousness, that is, the alert state that keeps us awaken, depends on Ascendant Reticular Activating System, which is located at the core of the brainstem between the myelencephalon and the mesencephalon.Coma may be generated by several etiologies, causing damages in ARAS’s cortical activation. With the intention of facilitating the recovery from coma, programs of multisensorial stimulation (MS) were created aiming to stimulate ARAS and thus to assist in the recovery of the level of conscience of comatose patients. In view of this, the objective of this work was to analyze what the literature shows about the influence of multisensorial stimulation on the level of consciousness of coma patients. We did a literature survey in the electronic databases Medline, Cochrane, Scielo and Lilacs and in Pubmed and Highwire search sites. Articles selected cover the period 1983- 2007. Keywords used were: coma, sensorial stimulation, perception and rehabilitation. We included clinical assays focusing in MS for comatose patients, and excluded articles that had studied other forms of treatment in comatose patients that did not aimed at increasing the level of consciousness. Twenty scientific articles were analyzed that presented controversial results regarding the type of stimulation, time of duration of the therapy and results reached after the application of the multisensorial stimulation program in comatose patients. Although clinical indications pointed to improvements in the level of consciousness with the use of multisensorial stimulation, there is no scientific evidence of its effectiveness. No randomized clinical assay was located that really established the improvement of the level of...

El coma es una situación de la degradación extrema del nivel de conciencia (NC) donde el individuo permanece con los ojos cerrados, sin ninguna percepción del mundo externo, incapaz de comunicarse, contestar a los comandos ni de tener comportamientos elaborados. El nivel de conciencia, es decir, el estado de alerta que nos mantiene despiertos, depende del Sistema Activador Reticular Ascendente (SARA), que está situado en la base del tronco cerebral entre la parte trasera del cerebro y el mesencéfalo. El coma se puede generar por varias etiologías, causando daños en la activación cortical de ARAS. Con la intención de facilitar la recuperación del coma, se crearan programas de estímulo multi-sensorial (EM) para estimular el Sistema Activador Reticular Ascendente y asistir así a la recuperación del nivel de conciencia de pacientes comatosos. En vista de esto, el objetivo de este trabajo fue analizar qué la literatura muestra acerca de la influencia del EM en el nivel de conciencia de pacientes comatosos. Hicimos una encuesta sobre la literatura en las bases de datos electrónicas Medline, Cochrane, Scielo y Lilacs y en los sitios de búsqueda de Pubmed y de Highwire. Los artículos seleccionados cubren el período 1983- 2007. Las palabras claves usadas fueran: coma, estímulo sensorio, percepción y rehabilitación. Incluimos los análisis clínicos que se enfocaban en el estímulo multi-sensorial para pacientes comatosos, y excluimos los artículos que estudiaran otras formas de tratamiento en los pacientes comatosos que no tienen como objetivo aumentar el nivel de conciencia. Veinte artículos científicos fueran analizados porque presentaron resultados polémicos respecto al tipo de estímulo, la época de duración de la terapia y los resultados alcanzados después del uso del programa del estímulo multi-sensorial en pacientes comatosos. Aunque las indicaciones clínicas señalaron mejoras en el nivel de conciencia con el uso del estímulo multi-sensorial, no hay...

[The effect of intravenous laser irradiation of the blood on the brain bioelectrical activity in patients in the postcomatose period]. / Vliianie vnutrivennogo lazernogo oblucheniia krovi na bioélektricheskuiu aktivnost' mozga u bol'nykh v postkomatoznom periode.

The article presents clinical data on therapeutic effects of intravenous laser blood irradiation (BI) in severe alcohol intoxication complicated by alcohol coma. BI effectiveness was assessed by EEG changes within 3 postcomatose days. Changes in brain biopotentials in various postcomatose periods were unidirectional. Positive results were achieved after low-intensity laser radiation.

Clinical correlates and prognosis in early spindle coma.

OBJECTIVE: To determine the prognostic significance of spindle coma (SC) according to etiology and EEG reactivity. METHODS: We reviewed 15 patients with SC due to various causes within 8 days of coma to determine the prognostic significance of this EEG pattern. RESULTS: The outcome among survivors was favorable: among 13 survivors, 9 were independent in all activities of daily living (ADLs) at 6 months; 3 were dependent in all ADLs; and one remained in coma. EEG reactivity to noxious stimuli best predicted outcome: All patients (whatever the coma etiology) with EEG reactivity survived; conversely, not all patients without EEG reactivity died. CONCLUSION: In our patients, EEG reactivity independent of etiology predicted survival, neurological examination did not predict outcome. Most SC survivors had a meaningful recovery achieving all ADLs. From the literature, the cause of SC was predictive of outcome: encephalopathy, seizures and trauma had the best prognosis while hypoxia, CRA and structural lesions carried the worst. Literature review revealed that 23% of patients [56/242] died or remained in a persistent vegetative state (PVS). Best outcomes occurred when SC was due to drugs, encephalopathy or seizures: (0/14 died or were in a PVS). With trauma 15% [25/169] died or were in a PVS). Intermediate outcomes occurred with hypoxia and cardio-respiratory arrest (CRA): 33% [7/21] died or were in a PVS. The gravest outcomes occurred with brain-stem and cerebral infarctions, and tumors: 73% [22/30] died or were in a PVS.

Return to work (RTW) after head injury.

This study explored return to work (RTW) after head injury from survey data on 177 cases of head injury. Although 45% of the sample study did engage in some work-related activity only 19% were in competitive employment positions. Factors which were related to RTW after head injury were: age when injured, sex, length of loss of consciousness and Likert ratings of learning, motor and ambulation impairment. Many of those who did return to competitive employment did so in less demanding positions than held pre-injury. Limitations of the current study and suggestions for future research are ventured.

[Experiences with rehabilitation of children after severe head injuries (author's transl)]. / Praktische Erfahrungen in der Rehabilitation von Kindern nach schwerem Schädel-Hirn-Trauma.

In the Federal Republic of Germany, there are at present too few centers which are responsible for the rehabilitation of children and adolescents who receive severe head injuries. Up to now, attempts have been made to seek out the institutions responsible and to tabulate the rehabilitation opportunities they offer. Furthermore, the typical follow-up grades after severe head trauma will be mentioned and the necessary methods of treatment in each case ordered accordingly. The opportunity for clinical rehabilitation should first of all be accessible to all children and adolescents who suffer from such injuries; this can later be converted into out-patient rehabilitation. Time spent on the wards during this period in hospital varies, depending on the grade of retardation, ranging approximately from 6 weeks to 1 year for the less severe cases up to 4 years and occasionally longer for the severely retarded.