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A Systematic and Evidence-Based Approach to Clinical Management of Patients with Disorders of Consciousness

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Handbook on the Neuropsychology of Traumatic Brain Injury

Part of the book series: Clinical Handbooks in Neuropsychology ((CHNEURO))

Abstract

Disorders of consciousness include coma, the vegetative state, the minimally conscious state and the post-traumatic confusional state. These conditions exist along a two-dimensional continuum comprised of arousal (i.e., wakefulness) and awareness (i.e., recognition of self and environment). Accurately characterizing and distinguishing these disorders early after onset is critically important as diagnosis is closely linked to prognosis and drives clinical decision-making. Unfortunately, published rates of misdiagnosed consistently approach 40 % with most of the error accounted for by failure to detect consciousness when it is preserved. Misdiagnosis may limit access to medical and rehabilitation services and lead to premature withdrawal of life-sustaining care. In this chapter, we describe a systematic, evidence-based framework for clinical management of patients with DoC. The primary aim is to demonstrate how a standardized, multi-tiered approach to assessment organized around a structured “care map” can be instituted in the rehabilitation setting to inform diagnostic, prognostic and treatment decisions, ultimately improving the consistency and effectiveness of care.

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References

  1. Faul, M. X. L., Wald, M. M., & Coronado, V. (2010). Traumatic brain injury in the United States: Emergency department visits, hospitalizations and deaths, 2002-2006. Atlanta, GA: National Center for Injury Prevention and Control.

    Google Scholar 

  2. Posner, J. B., & Plum, F. (2007). Plum and Posner’s diagnosis of stupor and coma (4th ed., Vol. 14, 401p.). Oxford, England: Oxford University Press.

    Google Scholar 

  3. Multi-Society Task Force on PVS. (1994). Medical aspects of the persistent vegetative state (1). The New England Journal of Medicine, 330(21), 1499–1508.

    Article  Google Scholar 

  4. Quality Standards Subcommittee of the American Academy of Neurology. (1995). Practice parameters: Assessment and management of patients in the persistent vegetative state (summary statement). Neurology, 45(5), 1015–1018.

    Article  Google Scholar 

  5. Giacino, J. T., Ashwal, S., Childs, N., Cranford, R., Jennett, B., Katz, D. I., et al. (2002). The minimally conscious state: Definition and diagnostic criteria. Neurology, 58(3), 349–353.

    Article  PubMed  Google Scholar 

  6. Sherer, M., Nakase-Thompson, R., Yablon, S. A., & Gontkovsky, S. T. (2005). Multidimensional assessment of acute confusion after traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 86(5), 896–904.

    Article  PubMed  Google Scholar 

  7. Sherer, M., Yablon, S. A., Nakase-Richardson, R., & Nick, T. G. (2008). Effect of severity of post-traumatic confusion and its constituent symptoms on outcome after traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 89(1), 42–47.

    Article  PubMed  Google Scholar 

  8. Childs, N., Mercer, W., & Childs, H. (1993). Accuracy of diagnosis of persistent vegetative state. Neurology, 43(8), 1465–1467.

    Article  PubMed  Google Scholar 

  9. Andrews, K., Murphy, L., Munday, R., & Littlewood, C. (1996). Misdiagnosis of the vegetative state: Retrospective study in a rehabilitation unit. BMJ, 313(7048), 13–16.

    Article  PubMed Central  PubMed  Google Scholar 

  10. Schnakers, C., Vanhaudenhuyse, A., Giacino, J., Ventura, M., Boly, M., Majerus, S., et al. (2009). Diagnostic accuracy of the vegetative and minimally conscious state: Clinical consensus versus standardized neurobehavioral assessment. BMC Neurology, 9, 35.

    Article  PubMed Central  PubMed  Google Scholar 

  11. Giacino, J. T., Schnakers, C., Rodriguez-Moreno, D., Kalmar, K., Schiff, N., & Hirsch, J. (2009). Behavioral assessment in patients with disorders of consciousness: Gold standard or fool’s gold? Progress in Brain Research, 177, 33–48.

    Article  PubMed  Google Scholar 

  12. Dejong, G., Horn, S. D., Gassaway, J. A., Slavin, M. D., & Dijkers, M. P. (2004). Toward a taxonomy of rehabilitation interventions: Using an inductive approach to examine the “black box” of rehabilitation. Archives of Physical Medicine and Rehabilitation, 85(4), 678–686.

    Article  PubMed  Google Scholar 

  13. Lammi, M. H., Smith, V. H., Tate, R. L., & Taylor, C. M. (2005). The minimally conscious state and recovery potential: A follow-up study 2 to 5 years after traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 86(4), 746–754.

    Article  PubMed  Google Scholar 

  14. Katz, D. I., Polyak, M., Coughlan, D., Nichols, M., & Roche, A. (2009). Natural history of recovery from brain injury after prolonged disorders of consciousness: Outcome of patients admitted to inpatient rehabilitation with 1-4 year follow-up. Progress in Brain Research, 177, 73–88.

    Article  PubMed  Google Scholar 

  15. Estraneo, A., Moretta, P., Loreto, V., Lanzillo, B., Santoro, L., & Trojano, L. (2010). Late recovery after traumatic, anoxic, or hemorrhagic long-lasting vegetative state. Neurology, 75(3), 239–245.

    Article  PubMed  Google Scholar 

  16. Nakase-Richardson, R. W. J., Giacino, J. T., et al. (2012). Longitudinal outcome of patients with disordered consciousness in the NIDRR TBI model systems programs. Journal of Neurotrauma, 29(1), 59–65.

    Article  PubMed  Google Scholar 

  17. Giacino, J. T., Kalmar, K., & Whyte, J. (2004). The JFK Coma Recovery Scale-Revised: Measurement characteristics and diagnostic utility. Archives of Physical Medicine and Rehabilitation, 85(12), 2020–2029.

    Article  PubMed  Google Scholar 

  18. DiPasquale, M. C. W. (1996). J. The use of quantitative data in treatment planning for minimally conscious patients. The Journal of Head Trauma Rehabilitation, 11(6), 9.

    Article  Google Scholar 

  19. Schnakers, C., Majerus, S., Giacino, J., Vanhaudenhuyse, A., Bruno, M. A., Boly, M., et al. (2008). A French validation study of the Coma Recovery Scale-Revised (CRS-R). Brain Injury, 22(10), 786–792.

    Article  PubMed  Google Scholar 

  20. Lovstad, M., Froslie, K. F., Giacino, J. T., Skandsen, T., Anke, A., & Schanke, A. K. (2010). Reliability and diagnostic characteristics of the JFK Coma Recovery Scale-Revised: Exploring the influence of rater’s level of experience. The Journal of Head Trauma Rehabilitation, 25(5), 349–356.

    Article  PubMed  Google Scholar 

  21. Rappaport, M., Hall, K. M., Hopkins, K., Belleza, T., & Cope, D. N. (1982). Disability rating scale for severe head trauma: Coma to community. Archives of Physical Medicine and Rehabilitation, 63(3), 118–123.

    PubMed  Google Scholar 

  22. American Speech-Language-Hearing Association. (2003). National Outcomes Measurement System (NOMS): Adult speech-language pathology user’s guide. Rockville, MD: Author [Internet].

    Google Scholar 

  23. Strauss, E., Sherman, E. M. S., Spreen, O., & Spreen, O. (2006). A compendium of neuropsychological tests: Administration, norms, and commentary (3rd ed., Vol. xvii). Oxford, England: Oxford University Press. 1216p.

    Google Scholar 

  24. Schiff, N. D., Giacino, J. T., Kalmar, K., Victor, J. D., Baker, K., Gerber, M., et al. (2007). Behavioural improvements with thalamic stimulation after severe traumatic brain injury. Nature, 448(7153), 600–603.

    Article  PubMed  Google Scholar 

  25. Whyte, J., Nordenbo, A. M., Kalmar, K., Merges, B., Bagiella, E., Chang, H., et al. (2013). Medical complications during inpatient rehabilitation among patient with traumatic disorders of consciousness. Archives of Physical Medicine and Rehabilitation, 94(10), 1877–1883.

    Article  PubMed  Google Scholar 

  26. Sander, A. M. (2007). Brain injury and the family. NeuroRehabilitation, 22(1), 1–2.

    Google Scholar 

  27. Sinnakaruppan, I., & Williams, D. M. (2001). Family carers and the adult head-injured: A critical review of carers’ needs. Brain Injury, 15(8), 653–672.

    Article  PubMed  Google Scholar 

  28. Gan, C., Campbell, K. A., Gemeinhardt, M., & McFadden, G. T. (2006). Predictors of family system functioning after brain injury. Brain Injury, 20(6), 587–600.

    Article  PubMed  Google Scholar 

  29. Bond, A. E., Draeger, C. R., Mandleco, B., & Donnelly, M. (2003). Needs of family members of patients with severe traumatic brain injury. Implications for evidence-based practice. Critical Care Nurse, 23(4), 63–72.

    PubMed  Google Scholar 

  30. Teasdale, G., & Jennett, B. (1974). Assessment of coma and impaired consciousness. A practical scale. Lancet, 2(7872), 81–84.

    Article  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Spaulding Rehabilitation Hospital, 300 First Avenue, Charlestown, MA, 02129, USA

    Joseph T. Giacino Ph.D., Christopher G. Carter Psy.D., Carrie Charney M.S., CCC-SLP, Denise Ambrosi M.S., CCC-SLP, Matthew J. Doiron B.A., Seth Herman M.D. & Timothy Young M.D.

  2. Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, 02115, USA

    Joseph T. Giacino Ph.D.

  3. Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, MA, USA

    Joseph T. Giacino Ph.D.

  4. MGH Institute for Healthcare Professionals, Boston, MA, USA

    Joseph T. Giacino Ph.D. & Christopher G. Carter Psy.D.

  5. Harvard Medical School, Boston, MA, 02115, USA

    Christopher G. Carter Psy.D., Seth Herman M.D. & Timothy Young M.D.

Authors
  1. Joseph T. Giacino Ph.D.
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  2. Christopher G. Carter Psy.D.
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  3. Carrie Charney M.S., CCC-SLP
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  4. Denise Ambrosi M.S., CCC-SLP
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  5. Matthew J. Doiron B.A.
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  6. Seth Herman M.D.
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  7. Timothy Young M.D.
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Corresponding author

Correspondence to Joseph T. Giacino Ph.D. .

Editor information

Editors and Affiliations

  1. TIRR Memorial Hermann, Baylor College of Medicine, University of Texas Medical School at Houston, Houston, Texas, USA

    Mark Sherer

  2. Baylor College of Medicine/Harris Health System, Brain Injury Research Center, TIRR Memorial Hermann, Houston, Texas, USA

    Angelle M. Sander

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Giacino, J.T. et al. (2014). A Systematic and Evidence-Based Approach to Clinical Management of Patients with Disorders of Consciousness. In: Sherer, M., Sander, A. (eds) Handbook on the Neuropsychology of Traumatic Brain Injury. Clinical Handbooks in Neuropsychology. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-0784-7_7

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