Download Is There Anyone In There?

Is There Anyone In
There?
Treatment of the Minimally Conscious
Patient
Objectives
– Why: Increased volume of patients with more acute
needs requiring efficient and effective rehabilitation at
an earlier stage
– What: Intervention approach for Speech-Language
Pathologist to facilitate not just communication but full
sensory function including swallowing.
– Where: Rehabilitation hospital; participation at
LTAC/SNF; home health; family care (family training);
beginning stages while still in acute care
– When: Ideally within 1 year of injury onset but
evidence of progress post-1 yr onset
• Physical gain w/in 1st year vs. plateau
• Cognitive-Linguistic progress w/in 1st year vs. long term
progress
MEASURING PATIENT
FUNCTION
Rancho Los Amigos
1
•
Rancho Los Amigos (RLA) Levels of Cognitive Function
• An evaluation tool used by the rehabilitation team
• Eight levels to describe the patterns or stages of recovery
typically seen after brain injury ranging from Level I (No
Response) to Level VIII (Purposeful and Appropriate)
•
•
•
•
•
•
•
•
Level I: No Response
Level II: Generalized Response
Level III: Localized Response
Level IV: Confused & Agitated
Level V: Confused & Inappropriate
Level VI: Confused & Appropriate
Level VII: Automatic & Appropriate
Level VIII: Purposeful & Appropriate
Functional Independence
Measures (FIM)
•
The Functional Independence Measures is a measurement of
disability severity, not impairment
• FIM was designed to be administered comparatively and quickly to
generate data
• FIM is a seven-level scale which ranks individual performance of an
activity, taking into account their need for assistance from another
person or device.
• The amount of help needed is quantified into a numeric score.
• This level of assistance translates into the time and energy that one
person would have to expend to serve the needs of the other.
•
•
•
•
•
•
•
FIM 1 = Dependent
FIM 2 = Maximal Assistance (25-49%)
FIM 3 = Moderate Assistance (50-74%)
FIM 4 = Minimal Assistance (75-90%)
FIM 5 = Supervision (>90% with hands-off assistant)
FIM 6 = Modified Independent (>90% without assistance with modifications)
FIM 7 = Independent
Glasgow Coma Scale
•
Eye Opening
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–
–
–
•
Verbal Response
–
–
–
–
–
•
Spontaneous = 4
To Speech= 3
To Stimulus= 2
None= 1
Oriented=5
Confused=4
Inappropriate words=3
Incomprehensible sounds=2
None=1
Motor Response (best)
–
–
–
–
–
–
Obeys commands=6
Localizes Stimulus=5
Flexion Withdrawal=4
Flexion Abnormal=3
Extension=2
None=1
•
GLASGOW OUTCOME
SCALE
– 5=Good Recovery (Normal or
Near Normal Recovery)
– 4=Moderate Disability
(Disabled but Independent)
– 3=Severe Disability
(Dependent with physical or
psychological disabilites or
both)
– 2=Persistent Vegetative State
– 1=Dead
Anatomy and Physiology
Key Anatomy
2
•
Consciousness consists of 2 major components:
– Arousal
– Awareness
•
Arousal: level of alertness
– Supported by function of the subcortical arousal systems in the
brainstem, midbrain and thalamus
– Clinically indicated by opening of eyes
•
Awareness: content of consciousness; awareness of environment
and self
– Supported by functional integrity of the cerebral cortex and its
subcortical connections
– Assessed by evaluating command following and observing non-reflex
motor behavior (eye tracking, localized responses to pain, etc.)
– Awareness of self assessed by patient’s response to autoreferential
stimuli (mirror image of his/her own face)
Anatomy
Terminology –
Differentiating between
Levels of Consciousness
9
Condition
Consciousne
ss
Sleep/Wake
Motor
Function
Auditory
Function
Visual
Function
Communicati
on
Emotion
Coma
None
Absent
Reflex and
postural
responses only
None
None
None
None
Vegetative
State
None
Present
Postures or
withdraws to
noxious stimuli
Startle
Startle
None
None
Occasional nonpurposeful
movement
Brief orienting to
sound
Brief visual
fixation
Localizes to
noxious stimuli
Localizes sound
location
Sustained visual
fixation
Contingent
vocalization
Reaches for
objects
Inconsistent
command
following
Sustained
visual pursuit
Inconsistent
but intelligible
verbalization
or gestures
Preserved
Preserved
Aphonic/
Anarthric
Minimally
Conscious
State
Partial
Present
Reflexive
crying or
smiling
Contingent
crying or
smiling
Holds or
touches objects
in a manner that
accommodates
size and shape
Automatic
movements
(e.g. scratching)
Locked In
Syndrome
Full
Present
Quadriplegic
Vertical eye
movement and
blinking
usually intact
Preserved
Brain Death
•
2
Brain Death: (American Academy of Neurology, 1995)
– Classically caused by massive brain lesion
• Trauma
• Intracranial hemorrhage
• Anoxia
– Demonstration of coma
– Evidence for cause of coma
– Absence of confounding factors, including hypothermia, drugs,
electrolyte and endocrine disturbances
– Absence of brainstem reflexes
– Absent motor responses
– Positive apnea testing
– Repeat evaluation in 6 hours is advised (but time period is arbitrary)
– Confirmatory laboratory tests only required when specific components
of the clinical testing cannot be reliably evaluated
– No recovery from brain death has ever been reported in the last 50
years in patients fulfilling these clinical criteria
Coma
•
•
•
•
2
Coma: complete failure of the arousal system with no spontaneous
eye opening and are unable to be awakened by application of
vigorous sensory stimulation
Time limited condition leading either to death, to recovery of
consciousness, or to transition to vegetative state
Results from bihemispheric diffuse cortical or white matter damage
or brainstem lesions bilaterally, affecting the subcortical reticular
arousing systems
After 3 days of observation, poor outcome heralded by:
–
–
–
–
Absence of pupillary or corneal reflexes
Stereotyped or absent motor response to noxious stimuli
Bilateral absent cortical responses of somatosensory evoked potentials
For anoxic coma: biochemical markers (high level of serum neuron
specific enolase)
Vegetative State (VS)
2
• State of arousal without awareness
• Usually caused by diffuse lesions in gray and
white matter
• Can transition to further recovery or it may be
permanent
• Vegetative state: complete absence of
behavioral evidence for self or environment
awareness. There is preserved capacity for
spontaneous of stimulus induced arousal,
evidenced by sleep-wake cycles
Vegetative State
• Criteria for Diagnosis (1994 Multi-Society Task Force)
– No evidence of awareness of self or environment and an inability
to interact with others
– No evidence of sustained, reproducible, purposeful, or voluntary
behavioral responses to visual, auditory, tactile or noxious stimuli
– No evidence of language comprehension or expression
– Intermittent wakefulness manifested by the presence of sleepwake cycles
– Sufficiently preserved hypothalamic and brainstem autonomic
functions
– Bowl and bladder incontinence
– Variably preserved cranial nerve and spinal reflexes
“Permanent”
Vegetative State
2
• Refers to patients whose chances of recovery
are close to zero
• Refers to cases of VS that last more than 1 year
after traumatic injury or 3 months after
nontraumatic injury
• VS is characterized as “persistent” when the
patient is in this state for >1 month
• Suggested to avoid this abbreviation as both
Permanent and Persistent are PVS
• Instead mention the etiology and the time spent
in VS
Minimally Conscious
State
2
• MCS patients manifest at least on of the following:
– Purposeful Behavior
– Following Simple Commands
• MCS may be chronic and sometime permanent
• Emergence clinically defined by ability to exhibit
functional interactive communication or functional use of
objects
• Traumatic etiology has a better prognosis than nontraumatic anoxic brain injuries
• Minimally Conscious State: demonstrate discernable
behavioral evidence of consciousness but remain unable
to reproduce this behavior consistently.
Locked-In Syndrome
(LIS)
2
• Results from bilateral ventral pontine lesion
– Mesencephalic lesions also reported
• No dissociation between arousal and awareness
• LIS patients demonstrate: (1995 American
Congress of Rehabilitation Medicine)
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–
–
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Sustained eye opening (rule out bilateral ptosis)
Quadriplegia or quadriparesis
Aphonia or hypophonia
Primary mode of communication via vertical or lateral
eye movements, or blinking of the upper eyelid to
signal yes/no responses
– Preserved cognitive abilities
Locked-In Syndrome
2
Three categories:
1.Classic LIS: quadriplegia and anarthria with
eye-coded communication
2.Incomplete LIS: remnants of voluntary
responsiveness other than eye movements
3.Total LIS: complete immobility including all
eye movements, combined with preserved
consciousness
Assessment
Assessment of the Minimally
Conscious Patient
7
• The burden of proof for establishing diagnosis and prognosis in
patients with disorders of consciousness lies in behavioral
assessment methods
• Despite advances in Neuro-imaging and other technologies,
behavioral assessment methods remains the standard for
establishing diagnosis and prognosis in patients with DOC
• Two methodologies:
– Standardized rating scale - Primary indications include
differential diagnosis, outcome predictions, facilitating
interdisciplinary treatment planning and determining the
effectiveness of treatment interventions
– Individualized quantitative assessment procedures – focus on
case specific questions designed to increase diagnostic
specificity by exploiting the principles of single-subject design
Consciousness Scales
7
• Standardized Rating Scales
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Glasgow Coma Scale - GCS (1974)
Full Outline of UnResponsiveness - FOUR (2005)
Coma Recovery Scale – Revised - CRS-R (2004)
Rappaport Coma/Near-Coma Scale - C-NC (1987)
Sensory Modality Assessment and Rehabilitation
Technique - SMART (2004)
– Wessex Head Injury Matrix - WHIM (2000)
– Disorders of Consciousness Scale - DOCS (2005)
Consciousness
Scales
2, 7
•
•
•
•
Glasgow Coma Scale (GCS): measure eye, verbal, and motor
responsiveness
– Not sensitive enough to detect transition from VS to MCS
– Requires verbal response (cannot be performed accurately on
intubated patients)
Full Outline of Unresponsiveness (FOUR): measures eye, motor,
brainstem and respiratory function
– Advantage: does not need a verbal response (can use w/
intubated patients)
– Can discriminate between VS and MCS as it assesses visual
pursuit but does not test all behavioral criteria of MCS
– More sensitive in detecting LIS as it explicitly asks patients to
move their eyes on command
Coma Recovery Scale-Revised
Rappaport Coma/Near Coma Scale: Developed to measure small
clinical changes in patients with severe brain injuries along the
following seven parameters on a 0-4 scale
Consciousness
Scales
2, 7
•
•
•
SMART : The SMART protocol has two components: Informal and Formal
– The informal component involves the collation of information and
observations from the family, friends, and the multi-disciplinary team.
– The components of the Formal Section are Behavioural Observations of
the following eight modalities: Visual, Auditory, Tactile, Olfactory,
Gustatory, Motor function, Communication function
WHIM: Designed to pick up changes showing recovery and provide
objective evidence of tightly defined categories of observation covering
communication ability, cognitive skills and social interaction
DOCS: The test stimuli were organized into eight subscales: social
knowledge, taste and swallowing, olfactory, proprioceptive (perception of
one's body in space) and vestibular (balance), auditory, visual, tactile, and
testing-readiness. The investigators found that DOCS is an accurate means
to detect improvements, declines and plateaus in neurobehavioral
functioning in unconscious patients.
Assessment of the Minimally
Conscious Patient
7
• Individualized Quantitative Behavioral Assessment
– An alternative means to investigate behavior patterns in DOC
patients
– Recommended in use with a standardized measure
– Used to measure basic sensory functions, such as vision,
command following and communicative behavior
– Uses a standardized battery of stimuli presentation and
response scoring
– Based on a single subject experimental design in which the
association of the stimuli and the behavior are analyzed
– Objective is to elicit specific behaviors that are not just
coincidental
Assessment of the Minimally
Conscious Patient
2
• Estimated that 40% of VS patients are
misdiagnosed
• LIS diagnostic error also frequent –
– In many cases (unless physician is familiar with the
syndrome) years go by before the patient is
accurately diagnosed
– It is often the family that realizes the patient is
conscious
• High diagnostic error rate can be explained by
physical function in these patients, which is the
main way to exhibit their awareness
Misdiagnosis
2
• Proposed objective way to overcome obstacles
in misdiagnosis:
– Follow single case experimental designs
– Adapt assessment procedure on the patient’s
particular case (individualized quantitative behavioral
assessment)
– Identify a particular behavior that is tested for
consistency in response to command and it further
checks whether this behavior changes overtime,
either in response to treatment or spontaneously
Paraclinical Assessment
2
• EEG: informative of the general vigilance
level of patients and can detect functional
abnormalities (seizures)
– Most employ test to confirm brain death
• Evoked Potentials (EP’s): responses to
environmental stimuli may be more
informative of cognitive status of the
patient
– Derived statistically from the EEG
Paraclinical Assessment
2
• Evoked Electrophysiological (EE) responses:
signatures of neural activity that may
differentiate conscious from unconscious
processing and are ready to employ at the
patient’s bedside
• Functional Neuroimaging (FN): permits objective
measurement of the brain’s activity at rest and
during various stages of external stimulation
– Fluoro-edoxy-glucose PET (FDG-PET)
• Measures glucose metabolic levels
– Functional MRI (fMRI)
• Measures oxygen metabolic levels
Assessment –
Neuroimaging
2
• PET scans in brain death show absence of
neuronal metabolism in the whole brain (“emptyskull” sign)
• Cortical metabolism in coma and VS is reduced
by 40-50% of normal values
• Recovery from VS, however, is not always
associated with a return to near normal global
cerebral metabolic levels
• Metabolic changes are observed regionally
The JFK Coma Recovery
Scale-Revised (CRS-R)
15
• Developed to help characterized and monitor patient
functioning at Rancho Levels I – IV
• Original CRS met statistical requirements for
unidimensionality of neurobehavioral function and
equal interval measurement, it did not take into
account the diagnostic criteria from the Aspen
Group’s diagnostic criteria for MCS.
• Revised version addresses more information
required to more accurately diagnose the minimally
conscious state
The JFK Coma Recovery
Scale-Revised
15
• JFK Coma Recovery Scale-Revised
(CRS-R)
– Differentiates VS from MCS patients
– Similar structure to GCS, testing, in addition to
motor, eye and verbal responsiveness,
audition, arousal and communication abilities
– Assess every behavior according to the
diagnostic criteria of VS and MCS
– Approximately 15 minute administration time
The JFK Coma Recovery
Scale-Revised
15
• 23 items divided into Six subscales
– Auditory Function (0-4)
– Visual Function (0-5)
– Motor Function (0-6)
– Oromotor/Verbal Function (0-3)
– Communication (0-2)
– Arousal (0-3)
The JFK Coma Recovery
Scale-Revised
15
– Auditory Function (0-4)
•
•
•
•
•
4 – Consistent Movement to Command
3 – Reproducible Movement to Command
2 – Localization to Sound
1 – Auditory Startle
0 – None
The JFK Coma Recovery
Scale-Revised
15
• Visual Function (0-5)
•
•
•
•
•
•
5 – Object Recognition
4 – Object Localization: Reaching
3 – Visual Pursuit
2 – Fixation
1 – Visual Startle
0 – None
The JFK Coma Recovery
Scale-Revised
15
– Motor Function (0-6)
•
•
•
•
•
•
•
6 – Functional Object Use
5 – Automatic Motor Response
4 – Object manipulation
3 – Localization to Noxious Stimulation
2 – Flexion Withdrawal
1 – Abnormal Posturing
0 – None/Flaccid
The JFK Coma Recovery
Scale-Revised
15
– Oromotor/Verbal Function (0-3)
•
•
•
•
3 – Intelligible Verbalization
2 – Vocalization/Oral Movement
1 – Oral/Reflexive Movement
0 – None
The JFK Coma Recovery
Scale-Revised
15
– Communication (0-2)
• 2 – Functional: Accurate
• 1 – Non-functional: Intentional
• 0 – None
The JFK Coma Recovery
Scale-Revised
15
– Arousal (0-3)
•
•
•
•
3 – Attention
2 – Eye Opening without Stimulation
1 – Eye Opening with Stimulation
0 - Unarousable
Treatment Methods
Treatment of Minimally
Conscious Patients
11
• Standards of care have not been clearly established
to guide treatment of DOC patients
• Interventions include:
–
–
–
–
–
Pharmacologic interventions
Sensory Stimulation
Physical Management
Hyperbaric Oxygen therapy
Deep Brain Stimulation
• None have been empirically shown to restore
consciousness
Pharmacologic Rehabilitative
Interventions
2
• Generally, response of DOC patients to
pharmocologic treatments remains
unsatisfactory
• Studies have shown amantadine
(dopaminergic agent) was linked to better
outcome in traumatic DOC
• Levodopa, Bromocriptine, Baclofen, and
Zolpidem also have been recently shown
useful in treatment of DOC
Pharmacologic
Treatment
2
Drug name
Type
Purpose
Amantadine
Dopaminergic
agent
Dopaminergic
agent
Increased arousal
and awareness
Increased arousal,
awareness and
initiation
Bromocriptine
Levodopa
Baclofen
Zolpidem
Dopaminergic
agent
GABA agonist
Increased arousal
and awareness
Admin. Mainly
again spasticity
Nonbenzodiazepin Used against
e sedative drug
insomnia in
healthy people
Pharmacologic
Treatment
2
• Pharmacological changes can also impact
performance
– May help produce more reliable responses
– Neurotransmitters
• Dopamine
• Norepinephrine
– Psycho stimulants
• Methylphenidate
• Dextroamphetamine
– Neurological Enhancers
• Desipramine
• Amitriptyline
Non-pharmacologic
Treatment
2
•
•
•
•
•
Deep Brain Stimulation (DBS)
Sensory stimulation techniques
Physical therapy
Occupational therapy
Speech Language Therapy
Sensory Stimulation
2
1. Multisensory stimulation approach
•
•
2.
Embraces principles of behaviorism
Enhanced environmental stimulation of sensory
systems is hoped to enhance synaptic
reinnervations and eventually improve outcome
Sensory regulation approach
•
•
Based on principles of information processing
Focuses on enhancement of selective attention by
regulating the environment
*At present, the beneficial effects of all approaches
remain debated and not evidence based
Treatment –
Sensory Program
– Stimulate the senses
• Atypical interventions: AAT, thermal stimulation, etc.
• FULL APPROACH: Sight, sound, touch, temp, movement
• yes/no response – using all possibilities
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–
–
–
–
–
–
thumbs up/down
finger movements
mouse clicking
writing
eye blinks as a last resort (2/3 vs. ½)
verbal (not necessarily words)
eye gaze
Treatment - Interdisciplinary
approach
– Co-treatment
• Occupational Therapy, Physical Therapy, Therapeutic
Recreation, Respiratory Therapy, Music Therapy
• Group therapies
– Communication Skills group
– Social Interaction group
– Animal Assisted Therapy
• Positioning
• Involving the physician
• medications, IBC pump/Botox, shunt placement)
• Changes in status
Treatment –
Cognitive-Linguistic Deficits
– Cognitive-linguistic deficits
• Aphasia
• Apraxia
– Verbal Apraxia vs. limb Apraxia vs. Dysarthria
• Right hemiplegic Deficits
– Field cut vs. neglect
• Physical limitations
• poor initiation
• Inhibition
• delayed responses
• This will not be as standard as you would like it to be!
Treatment –
Sensory & Cognitive Issues
• Must maximize arousal levels but typical
assessment methods may not be suitable.
– Visual Function
– Auditory Function
Treatment –
Sensory & Cognitive Issues
– Taste
• Oral stimulation to taste, flavor, temperature and
texture
• Oral care
• Swallowing if appropriate
– Touch
• Tactile stimulation (face, hands, torso)
• Thermal stimulation
– Smell
• If trach is capped/no trach present ( to allow for
smell), use good and bad smells (noxious stimuli)
Assessing Change
•
May be more useful to track specific behaviors
–
–
–
–
•
Alertness
Reactions to sensory stimulation
Following Commands
Communication
Time frame for progress is possible at least 1 year post on-set
– Longer window for recovery with patients who sustained their injury
secondary to trauma
•
Can take a great deal of time
– Day-to-day changes not always significant
•
May not always happen in your facility
– Caregiver education becomes more important to notice the subtle
changes
– Can be very difficult at start of treatment given emotional impact of the
injury on a family
Eye tracking versus volitional
eye gaze
• Simple tracking: ability to visually focus on a
single point in 1 or more visual fields and/or
visually scan in immediate environment
• Volitional eye gaze: many times preserved in the
absence of tracking
• Functional clinical application:
– Do not rule out eye gaze if the patient is not passively
tracking
– Use verbal cueing only to see if patient is able to
utilize volitional eye gaze as a command following
task as opposed to passive eye gaze (i.e. look up at
the ceiling, look down towards the floor, etc.)
Auditory
Comprehension
•
•
•
•
With established Yes/No system, questions much be straight
forward
– Reliable Yes/No signals
• Eye blinks? Communication board Thumbs up/down
Accuracy of the system relies on consistent use of the system and
then accuracy of responses
– “Are you a man?” and “Are you a woman?” “Is your name ___?”
Be aware of limits and be open to re-evaluation of the system
– Change happens quickly
Following Commands
– How to tell if it is true or a coincidence
• Inventory of voluntary movements
– Squeeze vs. relax
Pointing
Communication
• Verbal Communication vs. Nonverbal vs.
Need for AAC
– Ethical questions
– Funding
– Using what you have
• can be a limiting factor
• Greatest helper and greatest foe
Speech
Considerations
•
•
•
•
•
•
•
•
•
•
•
APRAXIA
FATIGUE LEVEL/POTENTIAL TO FATIGUE
VISUAL PERCEPTION
PROGRESSIVE NATURE OF ILLNESS/INJURY
FUNDING
HOME ACCESSIBILITY
BI-LINGUAL CONSIDERATIONS
PHYSICAL LIMITATIONS
OVERALL COGNITIVE STRENGTHS/WEAKNESSES
HOME SITUATION
FAMILY/CAREGIVER FAMILIARITY/ABILITY TO BE
TRAINED ON DEVICE
Treatment - AAC
• KEEP THE PATIENT’S COGNITIVE
ABILITIES IN MIND AT ALL TIMES!
• Many times the patient’s physical abilities
will surpass their cognitive abilities or vice
versa (usually physical over cognitive)
• a mismatch between the 2 can be
frustrating and detrimental to the patient’s
progress
AAC Funding
• Private Insurance
• Medicare/Medicaid
• State funding
Dysphagia Management
Dysphagia Management
14
•
Patients with TBI are at risk of developing problems with eating,
swallowing and drinking
• Number of TBI patients has increased in recent years
• This creates increased risk for this life threatening condition
• Patients with TBI are admitted to an ICU are at high risk for
developing pneumonia
– In the earlier stages of recovery, pneumonia is most likely within an
average of 3 days and is associated with severe trauma
•
In the earlier stages of rehabilitation, it is even more important to
monitor the patient for:
– clinical signs of aspiration
– minimize risks for reflux
– manage the tracheotomy tube
-maintain good oral hygiene
-manage secretions
-manage oral feedings
Dysphagia Management
14
• Pneumonia is an inflammation in the lung parenchyma
and is defined as an appearance of new infiltrative
changes on chest radiograph or an increase in
temperature to more than 38.5 C.
• Hansen et al. (2008) found 27% of patient has
pneumonia upon admission while another 12%
developed pneumonia after admission
– 81% of those who had been diagnosed with pneumonia were
completely dependent on tube feedings
• Some patients with severe TBI produce more saliva and secretions,
which contribute to the increased risk for developing pneumonia
– it was more likely to occur within the first 15 days of admission
– Greater risk for those who had a low GCS score of (9 or less) or
a lower FIM score (less than 19)
Dysphagia Management
1
• Research indicates swallowing difficulties exist
in up to 61% of patients exhibiting DOC
– May be due to both the physiological and cognitive
deficits combined
• Swallowing may be overlooked as a treatment
modality
• Research has indicated that early onset of
swallowing intervention/dysphagia therapy can
be an excellent functional therapeutic tool
Dysphagia Management
1
• Some clinicians advocate providing RLA II
patients (generalized
responses/vegetative state) and RLA III
patients (localized responses/ MCS) with
food/liquid presentations for taste
stimulation
• Other clinicians advocate for no oral
feedings until the patient’s level of
consciousness improves beyond RLA III
Dysphagia Management
1
• 2006 study investigated Rancho Los Amigos
levels and the implementation of PO
intake/dysphagia therapy in patients exhibiting
DOC
• Diet levels coded regular, modified, therapeutic
feeding, or nil per os (NPO)
– Regular: 3 meals/day with no restrictions
– Modified: 3 meals/day with alteration in solid/liquid
– Therapeutic: small controlled amounts of food/liquid
provided by an SLP for practice swallows (3 boluses6oz intake)
– NPO: all nutrition received via tube; pt’s receiving
taste stimulation were considered NPO
Dysphagia Management
1
• Previous research has reported that taste stimulation for
pt’s at RLA level II and III was possible and safe
following appropriate clinical clearance
• This study found that it was safe to provide therapeutic
oral feedings to patients functioning at RLA III if the
patient
1. Does not demonstrate aspiration or aspiration is eliminated with
volume or consistency modification on a baseline instrumental
swallowing exam (i.e. FEES, VFSS, or MBS)
2. Is given close supervision during oral feeding
• IMPORTANT: The decision to introduce food or liquid to
the mouth in an actual bolus with this patient population
should only be made after the completion of VFSS,
FEES or MBS (no blue dye)
Dysphagia Management
1
• Study shows that early therapeutic feedings may
enhance quality of life by providing pleasure for
the patient and their families
• There is no direct evidence linking initiation of
oral feeding early in coma recovery (RLA III) with
improved cognition, however, evidence of an
association between participants who were able
to resume oral feeding at some time during their
IP rehab with improved cognitive status was
reported
Medical Complications
Medical Complications in
minimally conscious patients
19
• Tachycardia – can be caused by
hypovolemia, anemia, cardiac
abnormalities (pre-morbid or secondary to
trauma), or pain.
• Must monitor blood pressure and other lab
results as well as the electrocardiogram.
• Monitor for pressure sores, abdominal
abnormalities and sores caused by lip
biting, etc to rule out issues of pain
Medical Complications
(continued)
19
• Fever – can be caused by infections,
medications, aspiration without
pneumonia, pancreatitis and
thrombophlebitis.
• Treatment is usually symptomatic.
Medical Complications
(continued)
19
• Hypertension – Common in vegetative
state and minimally conscious patients
because of the location of the brain injury.
• Treatment may be pharmacological, such
as use of a beta blocker.
Medical Complications
(continued)
19
• Medications – Side effects can be
particularly problematic for MCP because
patients may not be able to report
subjective sedation, side effects may have
a greater impact on the cognitive function
of low level patients.
– i.e. medication regarding past and present
seizure activity.
Medical Complications
(continued)
19
• Post-Traumatic Epilepsy- The minimally
conscious patient is at a higher risk to
develop PTE .
• Treatment regimen may include
anticonvulsants, but amounts much be
closely monitored to avoid other side
effects.
Medical Complications
(continued)
19
• Post-Traumatic Hydrocephalus – May
cause prolonged periods of low
responsiveness.
• Diagnosis with a lumbar puncture may be
required to diagnose.
• Treatment may include a shunt to relieve
pressure, but the procedure could lead to
other complications.
Medical Complications
(continued)
19
• Heterotopic Ossification – A rigid
deformity which vegetative and minimally
conscious patients are at risk to develop
due to prolonged unconsciousness and
frequently spastic quadriparesis.
– Patient may also be at greater risk for
developing bed sores, so seating/positioning
becomes more crucial.
Medical Complications
(continued)
19
• Hypertonia and Motor Control – hypertonic
posturing may lead to contracture,
difficulty positioning, poor hygiene
management and motor function.
• Treatments include medications, but these
may sedate the patient make it more
difficult for the patient to show signs of
arousal.
Medical Complications
(continued)
19
• Decannulation – depending on the time
since onset, the patient may or may not
have a trach tube.
• Maintenance is a controversial issue
Medical Complications
(continued)
19
• Feeding – PEG likely given time for
recovery, or possibly NG tube to meet
nutritional needs.
• May start swallowing protocol early in
recovery, but not likely to meet nutritional
needs.
Medical Complications
(continued)
19
• Bruxism – severe grinding of the teeth
which many believe will help to improve
with recovery, so it may not be addressed.
• Risk exists to loosen teeth and harm
dental surfaces.
• Mouth guards may be used
CURRENT RESEARCH AND
RESEARCH INDICATIONS
Current Research –
MCS
16
• Giacino/Kalmar studied 37 MCS patients
(s/p TBI) at 12 months post trauma
• On the Disability Rating Scale (DRS)
outcomes were as follows:
– 10% no disability
– 13% mild or partial disability
– 50% moderate to moderate severe range
– 10% severe disability range
– 17% extremely severe disability
Current Research –
MCS
16
• In comparison with the VS group in the
same study
– 10% died within the 1st year post trauma
– 33% vegetative
– 73% severe (or greater) disability range
– 3% moderate disability
– Results note better outcomes for pt’s in the
MCS state rather than the VS state as well as
good possibility for long term outcome for one
in the MCS state
Current Research –
MCS
16
• Sazbon and Groswasser studied 72 patients at least 12
months post onset and related their outcome to FIM
recovery
– Those that did not emerge from MCS state in 6 months or less =
dependent mobility and ADL’s (FIM 1)
– Variable results for patients in MCS between 31 and 60 days
• 55% independent in Mobility (FIM 7)
• 66% independent in ADL’s (FIM 7)
• 11% in gainful employment (FIM 7)
– 26% demonstrated aphasia
– 42% demonstrated behavior disturbance
– 95% demonstrated (unspecified) cognitive disorders
Current Research –
MCS
16
• Most recently (2005) – ACRM and AAPMR
sponsored a study investigating long term
recovery (2-5 years post injury) for MCS
patients
• Selection criteria stipulated that he
participant had sustained a TBI, had been
classified as a level IV or lower on the
RLAS of cognitive functioning at admission
and was in an MCS state during inpatient
rehabilitation
Current Research –
MCS
16
• At 2-5 years on the FIM motor scale:
– 50% were independent (with and without
equipment) in eating, toileting, bladder, and
bowel control, bed and toilet transfers and
mobility (FIM 6-7)
– 50% (+) of participants required physical
assistance for dressing the upper body, stairs,
and grooming (FIM 4 or below)
– Across all tasks, supervision was the least
represented category (FIM 5)
Current Research –
MCS
16
• At 2-5 years post onset on the FIM cognitive
scale:
–
–
–
–
39% independent in expression (FIM 6-7)
22% independent in problem solving (FIM 6-7)
61% require assistance for expression (FIM 1-4)
67% require assistance for comprehension and social
interaction (FIM 1-4)
– 72% require assistance for memory (FIM 1-4)
– 78% require assistance for problem solving (FIM 1-4)
– Supervision (FIM 5) occurred more commonly in the
cognitive domain (11-33% across all items) than in
the motor domain (0-23% across all items)
Current Research –
MCS
16
• Main findings were the heterogeneity for the levels of
recovery in the sample of participant who had been in
the MCS for an extended period of time after TBI.
• Unexpected finding pertains to the patterns of
correlations between duration of the MCS and the
outcome variables
– i.e. measures of the initial severity of the injury, such as
durations of post-traumatic amnesia, have been shown to
significantly predict functional outcome
– Assumed that duration of MCS would be correlated in a similar
way, however, in this study correlations of duration of MCS and
level of recovery/psychosocial outcome were not significant.
Current Research –
Psychosocial Outcomes
16
• In the same study:
– 78% reported major changes in relationships with
partners compared with relationships with family
(17%)
• May be hypothesized that parents, in particular,
are better able to adopt the caregiver role
because of previous experience of caring for the
injured person as a child.
• By contrast, the spouse has generally not had
this type of experience with the person and may
require additional training and counseling
Current Research Impact of Rehabilitation
16
• The Minimally Conscious State and Recovery
Potential: A Follow-Up study 2-5 years after TBI
• Small sample (18 patients were followed)
• All had sustained a variety of head injuries
• FIM scores (motor scale) showed significant
proportions were functionally independent in
various activities with more than 50%
Independent, with or without equipment, in
eating, toileting, bowel and bladder control, bed
and toilet transfers and mobility
• Conversely, 50% required physical assistance
for UE dressing, stairs and grooming
Current Research Impact of Rehabilitation
16
• FIM Cognitive scale showed functional I (level 6 or 7) for
expression (39% I) to problem solving (22% I) Supervision
required for 61% in expression, and 67% for both
comprehension and social interaction, 72% for memory
and78% for problem solving.
• Supervision more prevalent in cognitive domain than in motor
domain
• Few studies have addressed longer term outcomes from the
MCS to different levels of recovery. A majority showed
significant improvement in basic daily activities, all
participants had life long support requirements. Almost 80%
were living at home, but only by virtue of their family’s
extraordinary efforts.
• Duration of MCS did not predict psychosocial outcomes, nor
did it preclude significant functional recovery.
Current Research Early Intervention
2
• There is evidence that early and increased
intervention leads to better outcome
• VS and MCS patients often denied early
intervention due to
– Slow progress
– Professional estimates that they have already
achieved the final level of responsiveness
– Their need to be on the waiting list for a
specialized rehabilitation center
Future Research
Needs
• Need for standardized, validated
behavioral scales
• Need for alternative non-motor dependent
means for assessment of DOC
Patient Care Issues:
Managed Care/Length of Stay
– The market has changed – reality dictates a
different plan of care in some cases
– Multiple/stages admits
– Continuum of care
•
•
•
•
•
Outpatient
SNF
LTAC
Home/Home Health
IMPORTANT THAT OUTPT IS NEURO BASED – NOT
ORTHO
– Be friends w/ SOCIAL WORK AND CASE
MANAGEMENT!
– FOLLOW-UP!
Patient Care Issues:
Managed Care/Length of Stay
1
• For patients whose injuries result in prolonged
LOC, it has been reported that lifetime care
costs range from $600,000 to $1,875,000
• Previous studies indicate that direct and indirect
costs of TBI in the US in 1995 alone totaled
$56.3 billion
• Average costs for IP TBI rehabilitation has been
estimated at $43,212 per person and $52,001
with equal average LOS of 47 days
• 2006 studies indicated findings consistent with
the 1995 studies indicating stable, if not rising
costs of care for these patients
Patient Care Issues:
Managed Care/Length of Stay
•
Acute Course
– ER staff to confirm diagnosis of coma
• Absence of eye opening, decerebrate posturing, bilateral pupil abnormalities and
loss of consciousness
• Initial CT showing scattered punctate hemorrhages throughout the cortex
•
Rehabilitation Course
– Team approach to care
– Primary determinants of outcome following TBI include
•
•
•
•
•
Length of time post injury
Severity of disability on admission to rehabilitation
Level of consciousness
Rate of recovery should be monitored systematically for prognostic accuracy
Clinicians should recognize that diagnosis, outcome predictions, and
response to treatment are largely based on probabilities and should
not be presented in absolute terms
Case Study
Case Study
• Patient was a 33 year old male status post severe
TBI/poly-trauma resulting from a motorcycle crash on
February 17, 2008.
• Other diagnoses: pneumonia, bilateral UE DVT,
respiratory failure, trach, anemia, HTN, spasticity,
hydrocephalus
• VP shunt already placed on 3/11/08 after follow up CT
revealed moderate ventriculomegaly
• Listed as minimally responsive
• No speech services received in the acute care setting
• Admitted to TIRR on March 24, 2008
• Over the course of the next 12 months, there were three
admissions. One extended stay after pump placement
at a Skilled Nursing Facility in the area.
Case Study Cont.
Case Study Cont.
•
Inpatient complications:
– storming
– kidney stones
•
Milestones:
– Passing MBS
• early meals
– Communication systems
•
•
•
•
yes/no
mouse click
writing
first words
– Standing
– Walking
•
•
Triumphant Return
Moving from the miracle to the man
Case Study Cont.
• Meet the Man?
Question and Answer
• Any Questions?
How to reach us:
• Hannah Bass, M.S. CCC-SLP
– [email protected]
• Michael Gettleman, M.H.A.,M.A. CCC-SLP
– [email protected]
– TIRR Memorial Hermann Speech Therapy
Department: (713) 799-5002
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