[Prolonged disorder of consciousness after severe acquired brain injury in adults. New recommendations provide a basis for investigation and rehabilitation]. / Långvarig svår medvetande-störning efter hjärnskada hos vuxna - Nya rekommendationer ger underlag för utredning och rehabilitering.

After severe acquired brain injury some patients develop a prolonged disorder of consciousness (vegetative state or minimally conscious state), and as such cannot actively participate in neurorehabilitation. However, international opinion and recent research developments emphasize the need for involvement of rehabilitation medicine units in the care of these patients. The article presents recommendations for the care of adult patients with prolonged disorders of consciousness, which have been developed by a multidisciplinary working party, in order to promote good care, and identify areas for further improvements.

Disorders of consciousness: preliminary data supports added value of extended behavioural assessment.

BACKGROUND: The use of validated behavioural assessment scales in assessment of patients with Disorders of Consciousness (DOC) is well established. However, there is little evidence to guide decisions on total time spent in behavioural assessment. OBJECTIVE: To assess whether brief behavioural assessment was as effective as extended behavioural assessment in detecting non-vegetative behaviours. METHODS: Consecutive patients with suspected DOC were assessed with two standardized instruments: Coma Recovery Scale Revised (CRS-R) and Sensory Modality Assessment and Rehabilitation Technique (SMART). Assessors were blinded to results from the other scale at the point of assessment. Two administrations of CRS-R together took 50-60 minutes ('brief' assessment). One complete SMART assessment took 600 minutes ('extended' assessment). Patients were classified as being in a vegetative state (VS) or minimally conscious state (MCS)/emerged from minimally conscious state (EMCS), following brief and extended assessment. RESULTS: Ten patients were assessed. Brief and extended assessment yielded the same diagnostic category (VS or MCS) for six patients and different categories for four, with extended assessment detecting higher level behaviours. CONCLUSIONS: Brief behavioural assessment was not as effective as extended assessment in detecting non-vegetative behaviours. Total time spent in behavioural assessment is likely important. Further studies and clearer clinical guidance are needed.

Opportunity for inpatient brain injury rehabilitation for persons in a vegetative state: survey of Swedish physicians.

OBJECTIVE: : The aim of this study was to document physicians' opinions on inpatient rehabilitation care for working-age patients in vegetative state after new acquired brain injury, given the absence of an established standard of post-acute care. DESIGN: : A postal survey of 3259 Swedish physicians was conducted. RESULTS: : Survey response rate was 33%. Of survey respondents, 51% reported that they knew the definition of vegetative state. Transfer of vegetative patients from acute care to inpatient rehabilitation was considered always warranted by 54% and never or only sometimes warranted by 31% of survey respondents, whereas 15% did not know or did not answer. Rehabilitation physicians most often considered an inpatient rehabilitation stay of around 3 mos to be appropriate, but there was a lack of consensus. Discharge from acute care direct to social care at least sometimes was reported by 39% of physicians. CONCLUSIONS: : Physicians' opinions vary considerably on appropriate post-acute care for patients in vegetative state after acquired brain injury. This may impact on rates of referral and admission to rehabilitation units. Consensus is needed on a minimum period for and extent of rehabilitation interventions. Educational interventions should be targeted broadly to reach the wide range of specialties that may have responsibility for acute care of these patients.

Nutritional treatment of patients with severe traumatic brain injury during the first six months after injury.

OBJECTIVE: This study explored current nutritional treatment policies and nutritional outcome in patients with severe traumatic brain injury. METHODS: We performed a retrospective, structured survey of the medical records of 64 patients up to 6 months after injury or until the patients were independent in nutritional administration. RESULTS: Enteral nutrition was administered to 86% of patients. Fourteen patients (22%) had a gastrostomy; after 6 months four were still in use. At 6 months, 92% of patients received all food orally and 84% had gained nutritional independence. Energy intake was equal to the calculated basal metabolic rate throughout the first month after injury and increased by 21% during the second month. Sixty-eight percent exhibited signs of malnourishment with weight losses of 10-29%. CONCLUSION: This study suggests that most patients with severe traumatic brain injury regain their nutritional independence within the first 6 months after injury, but also that most develop signs of malnutrition.