Assessment of Nociception and Pain in Participants in an Unresponsive or Minimally Conscious State After Acquired Brain Injury: The Relation Between the Coma Recovery Scale-Revised and the Nociception Coma Scale-Revised.

OBJECTIVES: To investigate the relation between consciousness and nociceptive responsiveness (ie, Nociception Coma Scale-Revised [NCS-R]), to examine the suitability of the NCS-R for assessing nociception in participants with disorders of consciousness (DOC), and to replicate previous findings on psychometric properties of the scale. DESIGN: Specialized DOC program. SETTING: Specialized DOC program and university hospitals. PARTICIPANTS: Participants (N=85) diagnosed with DOC. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We prospectively assessed consciousness with the Coma Recovery Scale-Revised (CRS-R). Responses during baseline, non-noxious, and noxious stimulations were scored with the NCS-R and CRS-R oromotor and motor subscales. RESULTS: CRS-R total scores correlated with NCS-R total scores and subscores. CRS-R motor subscores correlated with NCS-R total scores and motor subscores, and CRS-R oromotor subscores correlated with NCS-R total scores as well as verbal and facial expression subscores. There was a difference between unresponsive wakefulness syndrome and minimally conscious state in the proportion of grimacing and/or crying participants during noxious conditions. We replicated previous findings on psychometric properties of the scale but found a different score as the best threshold for nociception. CONCLUSIONS: We report a strong relation between the responsiveness to nociception and the level of consciousness. The NCS-R seems to be a valuable tool for assessing nociception in an efficient manner, but additional studies are needed to allow recommendations for clinical assessment of subjective pain experience.

[Costs associated with multiresistant bacteria in neurorehabilitation]. / Mehrkosten durch multiresistente Erreger in der Neurorehabilitation.

BACKGROUND AND OBJECTIVES: The number of patients with multiresistant bacteria (MRB) in rehabilitation facilities is increasing. The increasing costs of hygienic isolation measures reduce resources available for core rehabilitation services. In addition to the existing lack of care, patients with MRB are at further risk of being given lower priority for admission to rehabilitation facilities. Therefore, the Hygiene Commission of the German Society for Neurorehabilitation (DGNR) attempted to quantify the overall risk for deterioration of rehabilitation care due to the financial burden of MRB. MATERIALS AND METHODS: To analyze the added costs associated with the rehabilitation of patients with MBR, the DGNR Hygiene Commission identified criteria for a cost assessment. Direct (consumables, personnel and miscellaneous costs) and indirect costs of loss of opportunity were evaluated in seven neurorehabilitation centers in different states across Germany. RESULTS: On average, hygienic isolation measures amounted to direct costs of 144 € per day (47 € consumables, 92 € personnel, 5 € for other costs such as extra transportation expenditure) and indirect costs of 274 €, totaling 418 € per patient with MRB per day. Given that approximately 10% of patients had MRB, the added costs of hygienic isolation measures equaled about one tenth of the overall budget of a rehabilitation center and can be expected to rise with the increasing numbers of patients with MRB. CONCLUSIONS: Admission of patients carrying MRB to neurorehabilitation centers triggers added costs that critically diminish the overall capacity for centers to provide their core rehabilitation services.

Placebo-controlled trial of amantadine for severe traumatic brain injury.

BACKGROUND: Amantadine hydrochloride is one of the most commonly prescribed medications for patients with prolonged disorders of consciousness after traumatic brain injury. Preliminary studies have suggested that amantadine may promote functional recovery. METHODS: We enrolled 184 patients who were in a vegetative or minimally conscious state 4 to 16 weeks after traumatic brain injury and who were receiving inpatient rehabilitation. Patients were randomly assigned to receive amantadine or placebo for 4 weeks and were followed for 2 weeks after the treatment was discontinued. The rate of functional recovery on the Disability Rating Scale (DRS; range, 0 to 29, with higher scores indicating greater disability) was compared over the 4 weeks of treatment (primary outcome) and during the 2-week washout period with the use of mixed-effects regression models. RESULTS: During the 4-week treatment period, recovery was significantly faster in the amantadine group than in the placebo group, as measured by the DRS score (difference in slope, 0.24 points per week; P=0.007), indicating a benefit with respect to the primary outcome measure. In a prespecified subgroup analysis, the treatment effect was similar for patients in a vegetative state and those in a minimally conscious state. The rate of improvement in the amantadine group slowed during the 2 weeks after treatment (weeks 5 and 6) and was significantly slower than the rate in the placebo group (difference in slope, 0.30 points per week; P=0.02). The overall improvement in DRS scores between baseline and week 6 (2 weeks after treatment was discontinued) was similar in the two groups. There were no significant differences in the incidence of serious adverse events. CONCLUSIONS: Amantadine accelerated the pace of functional recovery during active treatment in patients with post-traumatic disorders of consciousness. (Funded by the National Institute on Disability and Rehabilitation Research; ClinicalTrials.gov number, NCT00970944.).

Integration of intensive care treatment and neurorehabilitation in patients with disorders of consciousness: a program description and case report.

Severe brain injuries frequently result in disorders of consciousness, requiring intensive care unit treatment. We present a rehabilitative system that integrates neurorehabilitation into intensive care treatment. The system will be described using the case report of a young man who was in a vegetative state after a severe traumatic brain injury that resulted in major medical problems and complications. Despite these challenges, interdisciplinary therapies can be applied throughout the rehabilitative process. The patient in our case report showed significant improvements and functional gains during the course of treatment. Additional data from other patients support the feasibility of this system and show that integrating neurorehabilitation into intensive care treatment is possible and can lead to improved outcomes in this patient population. We will discuss the advantages, special features, and limitations of the system. Additional studies are needed to further demonstrate the efficacy of this approach compared with standard treatment.

The Neurological Rehabilitation of Adults With Coma and Disorders of Consciousness.

BACKGROUND: Severe quantitative disorders of consciousness (DoC) due to acute brain injury affect up to 47% of patients upon admission to intensive care and early rehabilitation units. Nevertheless, the rehabilitation of this vulnerable group of patients has not yet been addressed in any German-language guidelines and has only been studied in a small number of randomized clinical trials. METHODS: In an S3 clinical practice guideline project, a systematic literature search was carried out for interventions that could improve consciousness in patients with coma, unresponsive wakefulness syndrome, or minimally conscious state after acute brain injury, and an evidence-based evaluation of these interventions was performed. Recommendations concerning diagnostic methods and medical ethics were issued by consensus. RESULTS: Misdiagnoses are common in patients with DoC, with minimal consciousness often going unrecognized. Patients with DoC should, therefore, be repeatedly assessed with standardized instruments, particularly the Coma Recovery Scale-Revised. The literature search yielded 54 clinical trials, mostly of low quality; there were two randomized controlled clinical trials providing level 1 evidence. The best available evidence for the improvement of impaired consciousness is for the administration of amantadine (4 studies) and for anodal transcranial direct-current stimulation of the left dorsolateral prefrontal cortex in patients in the minimal conscious state (8 studies, 2 systematic reviews). Further important components of rehabilitation include positioning methods and sensory stimulation techniques such as music therapy. CONCLUSION: For the first time, evidence-based German-language clinical practice guidelines have now become available for the neurological rehabilitation of patients with DoC.

Predictors of outcome in prolonged posttraumatic disorders of consciousness and assessment of medication effects: A multicenter study.

OBJECTIVES: To develop predictive models of recovery from the vegetative state (VS) and minimally conscious state (MCS) after traumatic brain injury (TBI) and to gather preliminary evidence on the impact of various psychotropic medications on the recovery process to support future randomized controlled trials. Design Longitudinal observational cohort design, in which demographic information, injury and acute care history, neuroimaging data, and an initial Disability Rating Scale (DRS) score were collected at the time of study enrollment. Weekly follow-up data, consisting of DRS score, current psychoactive medications, and medical complications, were gathered until discharge from inpatient rehabilitation. SETTING: Seven acute inpatient rehabilitation facilities in the United States and Europe with specialized programs for treating patients in the VS and MCS. PARTICIPANTS: People with TBI (N=124) who were in the VS or MCS 4 to 16 weeks after injury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: DRS score at 16 weeks after injury and time until commands were first followed (among those participants demonstrating no command following at study enrollment). Results DRS score at enrollment, time between injury and enrollment, and rate of DRS change during the first 2 weeks of poststudy observation were all highly predictive of both outcomes. No variables related to injury characteristics or lesions on neuroimaging were significant predictors. Of the psychoactive medications, amantadine hydrochloride was associated with greater recovery and dantrolene sodium was associated with less recovery, in terms of the DRS score at 16 weeks but not the time until commands were followed. More detailed analysis of the timing of functional improvement, with respect to the initiation of amantadine provided suggestive, but not definitive, evidence of the drug's causal role. CONCLUSIONS: These findings show the feasibility of improving outcome prediction from the VS and MCS using readily available clinical variables and provide suggestive evidence for the effects of amantadine and dantrolene, but these results require confirmation through randomized controlled trials.