Temporal Profile of Recovery of Communication in Patients With Disorders of Consciousness After Severe Brain Injury

Association of Patient Characteristics With Recovery in Adults With Disorders of Consciousness

OBJECTIVE

To describe the characteristics of patients enrolled in disorders of consciousness (DoC) rehabilitation programs and to examine factors associated with improvement beyond measurement error on neurobehavioral function. Outcomes for adults with DoC after severe brain injury are highly variable and difficult to predict. Applying a minimal detectable change (MDC) threshold to change measures can identify help to distinguish true improvement or decline from random fluctuation. We also evaluated whether change in neurobehavioral function during the first 2 weeks of rehabilitation was associated with change between 2 and 4 weeks.

DESIGN

Retrospective cohort study. Data were generated as part of standard clinical care.

SETTING

Postacute inpatient facilities with specialized DoC programs at 2 large, urban health care systems.

PARTICIPANTS

Adults with DoC after severe brain injury (N=696).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Improvement beyond measurement error, calculated as the MDC with a 90% confidence interval (9 units) on the Coma Recovery Scale-Revised (CRS-R), using an equal-interval 0-100 unit transformed total measure. The MDC threshold was applied to change in CRS-R total measure from first to last CRS-R administration (up to 60 elapsed).

RESULTS

Two-thirds of the sample (n=445) improved beyond the MDC on the CRS-R; 23 participants declined beyond measurement error, and 228 participants changed less than the MDC. Patients with less time elapsed between injury and first CRS-R assessment were more likely to improve beyond the MDC. Change during the first 2 weeks of rehabilitation was not associated with change between 2 and 4 weeks.

CONCLUSIONS

Our results underscore the importance of measuring change with greater precision for adults with DoC, as within-state change (or lack thereof) could inform rehabilitation treatment decisions about whether interventions are working as intended.

Natural history of recovery and long-term outcome in critically ill patients with brain injury

PURPOSE OF REVIEW

To increase knowledge of the natural history of recovery and long-term outcome following severe traumatic brain injury (sTBI).

RECENT FINDINGS

Recovery of consciousness and complex behaviors that presage subsequent functional recovery frequently occurs well beyond the first 7 days after injury, which is typically the time period widely used in the ICU for prognostic decision-making and establishing goals of care for. Similarly, recovery of functional independence occurs between 1 and 10 years postinjury in a substantial proportion of patients who do not recover command-following during the acute hospitalization. Data from large, multicenter studies that systematically conduct long-term follow-up with well validated measures consistently indicate that the most common trajectory of recovery after 1 year postinjury is characterized by changes, not stability, in functional status.

SUMMARY

Evidence from large multicenter studies with well characterized samples focusing on recovery trajectories beyond 1 year postinjury challenge conventional beliefs about outcome after sTBI. Signs of consciousness frequently emerge following discharge from the ICU setting and prediction of death and dependency within the first few weeks after injury is unreliable. Clinician knowledge of the frequency and time course to recovery of key behavioral milestones is central to evidence-based prognostic counseling.

Navigating uncertainty: a reflexive thematic analysis of rehabilitation staff's perception of communicative interactions in Disorders of Consciousness and Posttraumatic Amnesia

PURPOSE

This study aims to improve our understanding of how communicative interaction is perceived by experienced rehabilitation staff working with patients with Disorders of Consciousness (DoC) and Posttraumatic Amnesia (PTA).

METHOD

This qualitative study involved five workshops guided by modified Nominal Group Technique with 22 professionals from six disciplines. Reflexive thematic analysis was employed for analysis.

RESULTS

Four main themes were developed: (1) Watching carefully for any reaction, (2) The Challenge of careful interpretation, (3) Framing the interaction, and (4) Valued knowledge for involving and communicating with the patient. Rehabilitation professionals exhibited awareness of minimal communicative behaviors but reported regular focus shifts from natural interactions to testing and validating behaviors as part of their clinical reasoning. The emphasis on reliability reflected insecurity in their interpretations. Although spontaneous interactions were recognized, they were often undervalued in favor of reproducible behaviors. Participants also stressed the importance of sharing communicative strategies to ensure consistent patient care.

CONCLUSION

The findings highlight the tension between ethical awareness and clinical reasoning, with staff prioritizing reliability over spontaneous communication. Structured support, training, and interprofessional collaboration are essential to help rehabilitation professionals navigate the complexities of DoC and PTA, ensuring that communicative interactions are effectively supported throughout recovery.

Emergence from Disorders of Consciousness: Optimizing Self-Agency Through Communication

Language and communication deficits are intrinsic to disorders of consciousness. This article will provide an overview of language and communication deficits that can significantly confound the accuracy of diagnostic assessment in these patients. Authors will also discuss interventions to promote early communication using assistive technology and augmentative communication rehabilitation strategies. Finally, this article will discuss the importance of family education as well as ethical considerations connected to the recovery of communication and adaptive strategies to support patient autonomy and enhance self-agency.

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.

Update on diagnosis in disorders of consciousness

INTRODUCTION

New guidelines regarding the diagnosis of disorders of consciousness (DOC) (such as vegetative state and minimally conscious state) have recently been published by the American Academy of Neurology and the European Academy of Neurology. This follows an impressive number of prospective studies performed on DOC and recent multi-centric studies with larger sample size, which have gathered precious information on the recovery of cohort of patients through years and which now call for a better management of patients with DOC.

AREAS COVERED

This review will discuss recent updates on the clinical entities of DOC, the challenges for an accurate diagnosis and the last developments in diagnostic tools.

EXPERT OPINION

The authors will also discuss the impact of the new guidelines on their way of diagnosing patients and how diagnosis will most likely change in a near future.