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Riganello F, Tonin P, Soddu A. I Feel! Therefore, I Am from Pain to Consciousness in DOC Patients. Int J Mol Sci 2023; 24:11825. [PMID: 37511583 PMCID: PMC10380260 DOI: 10.3390/ijms241411825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 07/13/2023] [Accepted: 07/20/2023] [Indexed: 07/30/2023] Open
Abstract
Pain assessment and management in patients with disorders of consciousness (DOC) is a challenging and important aspect of care, with implications for detecting consciousness and promoting recovery. This narrative review explores the role of pain in consciousness, the challenges of pain assessment, pharmacological treatment in DOC, and the implications of pain assessment when detecting changes in consciousness. The review discusses the Nociception Coma Scale and its revised version, which are behavioral scales used to assess pain in DOC patients, and the challenges and controversies surrounding the appropriate pharmacological treatment of pain in these patients. Moreover, we highlight recent evidence suggesting that an accurate pain assessment may predict changes in the level of consciousness in unresponsive wakefulness syndrome/vegetative state patients, underscoring the importance of ongoing pain management in these patients.
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Affiliation(s)
- Francesco Riganello
- Research in Advanced Neurorehabilitation, S. Anna Institute, 88900 Crotone, Italy
| | - Paolo Tonin
- Research in Advanced Neurorehabilitation, S. Anna Institute, 88900 Crotone, Italy
| | - Andrea Soddu
- Physics, and Astronomy Department, Western Institute for Neuroscience, University of Western Ontario, London, ON N6A 3K7, Canada
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Bonin EAC, Lejeune N, Szymkowicz E, Bonhomme V, Martial C, Gosseries O, Laureys S, Thibaut A. Assessment and management of pain/nociception in patients with disorders of consciousness or locked-in syndrome: A narrative review. Front Syst Neurosci 2023; 17:1112206. [PMID: 37021037 PMCID: PMC10067681 DOI: 10.3389/fnsys.2023.1112206] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/06/2023] [Indexed: 04/07/2023] Open
Abstract
The assessment and management of pain and nociception is very challenging in patients unable to communicate functionally such as patients with disorders of consciousness (DoC) or in locked-in syndrome (LIS). In a clinical setting, the detection of signs of pain and nociception by the medical staff is therefore essential for the wellbeing and management of these patients. However, there is still a lot unknown and a lack of clear guidelines regarding the assessment, management and treatment of pain and nociception in these populations. The purpose of this narrative review is to examine the current knowledge regarding this issue by covering different topics such as: the neurophysiology of pain and nociception (in healthy subjects and patients), the source and impact of nociception and pain in DoC and LIS and, finally, the assessment and treatment of pain and nociception in these populations. In this review we will also give possible research directions that could help to improve the management of this specific population of severely brain damaged patients.
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Affiliation(s)
- Estelle A. C. Bonin
- Coma Science Group, GIGA-Consciousness Thematic Unit, GIGA-Research, Liège, Belgium
- Centre du Cerveau, Liège University Hospital, Liège, Belgium
| | - Nicolas Lejeune
- Coma Science Group, GIGA-Consciousness Thematic Unit, GIGA-Research, Liège, Belgium
- Centre Hospitalier Neurologique (CHN) William Lennox, Saint-Luc Hospital Group, Ottignies-Louvain-la-Neuve, Belgium
- Institute of Neuroscience, Université catholique de Louvain, Brussels, Belgium
| | - Emilie Szymkowicz
- Coma Science Group, GIGA-Consciousness Thematic Unit, GIGA-Research, Liège, Belgium
- Centre du Cerveau, Liège University Hospital, Liège, Belgium
| | - Vincent Bonhomme
- Department of Anesthesia and Intensive Care Medicine, Liège University Hospital, Liège, Belgium
- Anesthesia and Perioperative Neuroscience Laboratory, GIGA-Consciousness Thematic Unit, GIGA-Research, Liège, Belgium
| | - Charlotte Martial
- Coma Science Group, GIGA-Consciousness Thematic Unit, GIGA-Research, Liège, Belgium
- Centre du Cerveau, Liège University Hospital, Liège, Belgium
| | - Olivia Gosseries
- Coma Science Group, GIGA-Consciousness Thematic Unit, GIGA-Research, Liège, Belgium
- Centre du Cerveau, Liège University Hospital, Liège, Belgium
| | - Steven Laureys
- Coma Science Group, GIGA-Consciousness Thematic Unit, GIGA-Research, Liège, Belgium
- Centre du Cerveau, Liège University Hospital, Liège, Belgium
- Joint International Research Unit on Consciousness, CERVO Brain Research Centre, Centre Intégré Universitaire de Santé et Services Sociaux (CIUSS), University Laval, Québec City, QC, Canada
| | - Aurore Thibaut
- Coma Science Group, GIGA-Consciousness Thematic Unit, GIGA-Research, Liège, Belgium
- Centre du Cerveau, Liège University Hospital, Liège, Belgium
- *Correspondence: Aurore Thibaut,
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Lavezzi S, Bargellesi S, Cassio A, DE Tanti A, Gatta G, Hakiki B, Lombardi F, Montis A, Posteraro F, Scarponi F, Taricco M, Boldrini P, Cecchi F. Redefining a minimal rehabilitation assessment protocol for severe acquired brain injuries. Eur J Phys Rehabil Med 2022; 58:584-591. [PMID: 35666492 PMCID: PMC9980564 DOI: 10.23736/s1973-9087.22.07451-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The assessment of patients with severe Acquired Brain Injury (sABI) is mandatory in every phase and setting of care, and requires a multidimensional and interdisciplinary approach, to develop the individual rehabilitation project, and monitor long-term functional outcomes. In 2001 the Italian Society of Physical and Rehabilitation Medicine (SIMFER) published the minimal assessment protocol for traumatic sABI, providing a comprehensive, standardized functional assessment based on the International Classification of Functioning, Disability and Health (ICF), 2001. In 2007, a new protocol was published, extended to all sABI patients (PMGCA). In 2019, the SIMFER appointed a working group to provide a revised, updated version: the PMGCA2020. AIM The purpose of this study was to describe the minimal assessment protocol to be applied at every stage and setting of the care process of patients with sABI. METHODS The working group, including one neurologist and 11 physiatrists experts in sABI rehabilitation, performed a review of the international recommendations for sABI assessment focusing on the following key words: "sABI assessment," "sABI rehabilitation," "sABI prognostic factors," "sABI rehabilitation assessment," "sABI outcome," in MEDLINE. Revision and integration proposals by each member were written and motivated, discussed and voted. RESULTS The PMGCA2020 is addressed to sABI adult patients. It investigates the main clinical problems of sABI at any time of the rehabilitation pathway. It includes a demographic/anamnestic section, a clinical/functional assessment section and an outcome measures section following the ICF model of functioning and the model of the construction of the rehabilitation project. CONCLUSIONS The PMGCA2020 provides an updated tool for the multidimensional rehabilitation assessment of sABI patients, at any stage of the rehabilitation pathway. Further studies will allow the validation of this minimum set of variables paving the way to an assessment standardization of patients with sABI in the rehabilitation settings. CLINICAL REHABILITATION IMPACT This minimum set of variables, defining patient's functioning and clinical status and outcomes, at every stage and setting of the care process to provide a framework for the standardization of the clinical evaluation of patients with sABI in rehabilitation settings.
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Affiliation(s)
- Susanna Lavezzi
- Severe Brain Injury Rehabilitation Unit, Department of Neuroscience and Rehabilitation, S. Anna University Hospital, Ferrara, Italy
| | | | - Anna Cassio
- Physical and Rehabilitation Medicine, AUSL Piacenza, Piacenza, Italy
| | | | - Giordano Gatta
- Italian Society of Physical and Rehabilitation Medicine (SIMFER), Ravenna, Italy
| | - Bahia Hakiki
- IRCCS Don Carlo Gnocchi Foundation, Florence, Italy -
| | - Francesco Lombardi
- Department of Intensive Neurorehabilitation, Correggio Hospital, ASL Reggio Emilia, Reggio Emilia, Italy
| | - Andrea Montis
- Rehabilitation Medicine Unit, Ospedale Civile di Baggiovara, Modena University Hospital, Modena, Italy
| | - Federico Posteraro
- Department of Rehabilitation, Versilia Hospital, AUSL Toscana Nord Ovest, Camaiore, Lucca, Italy
| | - Federico Scarponi
- Department of Rehabilitation, San Giovanni Battista Hospital, ASL 3, Foligno, Perugia, Italy
| | - Mariangela Taricco
- Italian Society of Physical and Rehabilitation Medicine (SIMFER), Bologna, Italy
| | - Paolo Boldrini
- Italian Society of Physical and Rehabilitation Medicine (SIMFER), Rome, Italy.,European Society of Physical and Rehabilitation Medicine (ESPRM), Rotterdam, the Netherlands
| | - Francesca Cecchi
- IRCCS Don Carlo Gnocchi Foundation, Florence, Italy.,Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
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Bonin EAC, Binda Fossati ML, Filippini MM, Bornheim S, Lejeune N, O'Brien AT, Bodart O, Laureys S, Thibaut A, Chatelle C. Evaluation of the effect of analgesic treatment on signs of nociception-related behaviors during physiotherapy in patients with disorders of consciousness: a pilot crossover randomized controlled trial. Pain 2022; 163:e349-e356. [PMID: 34393202 DOI: 10.1097/j.pain.0000000000002367] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 04/12/2021] [Indexed: 11/27/2022]
Abstract
ABSTRACT Neuro-orthopedic disorders are common in patients with disorders of consciousness (DOC) and can lead to potential pain. However, the patients' inability to communicate makes pain detection and management very challenging for clinicians. In this crossover randomized double-blind placebo-controlled study, we investigated the effects of an analgesic treatment on the presence of nociception-related behaviors. At baseline, the Nociception Coma Scale-Revised (NCS-R) was performed in 3 conditions: a non-noxious stimulation, a noxious stimulation, and during a physiotherapy session. Patients with a NCS-R total score during physiotherapy equal or above the score observed after the noxious stimulation could participate to the clinical trial, as well as patients with a score above 5. They received an analgesic treatment and a placebo on 2 consecutive days in a randomized order followed by an assessment with the NCS-R. Of the 18 patients, 15 displayed signs of potential pain during physiotherapy. Patients showed higher NCS-R scores during physiotherapy compared with the other conditions, suggesting that mobilizations were potentially painful. Of these 15 patients, 10 met the criteria to participate in the placebo-controlled trial. We did not find any effect of analgesic treatment on the NCS-R scores. This study highlights that physiotherapy may be potentially painful for patients with DOC, while analgesic treatments did not reduced NCS-R scores. Therefore, careful monitoring with appropriate assessment and treatment before and during mobilization should become a priority in clinical settings. Future studies should focus on the development of assessment tools sensitive to analgesic dosage to manage pain in DOC.
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Affiliation(s)
- Estelle A C Bonin
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau (C ), University Hospital, Liège, Belgium
| | - Mariachiara L Binda Fossati
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Behavioral and Nervous System Sciences Department, University of Pavia, Pavia, Italy
| | - Maria M Filippini
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Neuromotor and Rehabilitation Department, AUSL-IRCSS of Reggio Emilia, Reggio Emilia, Italy
| | - Stephen Bornheim
- Department of Sport and Rehabilitation Sciences, University of Liège, Liège, Belgium
| | - Nicolas Lejeune
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau (C ), University Hospital, Liège, Belgium
- CHN William Lennox, Saint-Luc Hospital Group, Ottignies, Belgium
- Institute of Neurosciences, UCLouvain, Brussels, Belgium
| | - Anthony T O'Brien
- Independent Scholar, Aetna, CVS Health Company, Hartford, CT, United States
| | - Olivier Bodart
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
| | - Steven Laureys
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau (C ), University Hospital, Liège, Belgium
| | - Aurore Thibaut
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau (C ), University Hospital, Liège, Belgium
| | - Camille Chatelle
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau (C ), University Hospital, Liège, Belgium
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