Bedside patient engagement monitor for rehabilitation in disorders of consciousness - demonstrative case-reports.

AIM: A chronic disorder of consciousness (DOC) is a devastating condition for the patients and their families. Achieving improved communication with patients in this state is of utmost importance. Over recent years we have seen some progress in the development of rehabilitation protocols for patients with DOC by which the patient's limited actions impact the environment (e.g. activate music) based on the principle of contingent stimulation. However, one of the major factors, which hinders further progress, is the limited overt responsiveness of the patient, which poses a severe limitation on the ability of the therapists to evaluate whether specific interventions have an impact. In this work, we harness a novel electrophysiological marker the Brain Engagement Index (BEI), which enables simple monitoring of patient's engagement during interventions, intending to overcome this limitation. METHODS: We combine the BEI marker with the contingent stimulation principle, to propose a 4-levels protocol for advancing communication with DOC patients. RESULTS: The potential of the evolving protocol is demonstrated with 4 representative case reports. Each case report demonstrates one level of the protocol. CONCLUSIONS: The protocol seems to be both feasible and effective for better clarification of the communication abilities of DOC patients. We recommend its continued evaluation employing a more structured study.IMPLICATIONS FOR REHABILITATIONWe suggest a systematic method for rehabilitation of patients with disorders of consciousnessIt is based upon monitoring patient engagement in real-time and selecting interventions accordingly.

Detailed behavioral assessment promotes accurate diagnosis in patients with disorders of consciousness.

INTRODUCTION: Assessing the awareness level in patients with disorders of consciousness (DOC) is made on the basis of exhibited behaviors. However, since motor signs of awareness (i.e., non-reflex motor responses) can be very subtle, differentiating the vegetative from minimally conscious states (which is in itself not clear-cut) is often challenging. Even the careful clinician relying on standardized scales may arrive at a wrong diagnosis. AIM: To report our experience in tackling this problem by using two in-house use assessment procedures developed at Reuth Rehabilitation Hospital, and demonstrate their clinical significance by reviewing two cases. METHODS: (1) Reuth DOC Response Assessment (RDOC-RA) -administered in addition to the standardized tools, and emphasizes the importance of assessing a wide range of motor responses. In our experience, in some patients the only evidence for awareness may be a private specific movement that is not assessed by standard assessment tools. (2) Reuth DOC Periodic Intervention Model (RDOC-PIM) - current literature regarding assessment and diagnosis in DOC refers mostly to the acute phase of up to 1 year post injury. However, we have found major changes in responsiveness occurring 1 year or more post-injury in many patients. Therefore, we conduct periodic assessments at predetermined times points to ensure patients are not misdiagnosed or neurological changes overlooked. RESULTS: In the first case the RDOC-RA promoted a more accurate diagnosis than that based on standardized scales alone. The second case shows how the RDOC-PIM allowed us to recognize late recovery and promoted reinstatement of treatment with good results. CONCLUSION: Adding a detailed periodic assessment of DOC patients to existing scales can yield critical information, promoting better diagnosis, treatment, and clinical outcomes. We discuss the implications of this observation for the future development and validation of assessment tools in DOC patients.