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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 – – – – • 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) – – – – 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 – – – – – 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 – – – – – – – 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 Sources 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. Brady, Susan L., Meghan Darragh, Nelson G. Escobar, Kara O'Neil, Theresa L-B Pape, and Noel Rao. "Persons with disorders of consciousness: Are oral feedings safe/effective?" Brain Injury 20.13-14 (2006): 1329-334. Print. 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