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ACRM endorsed practice guideline| Volume 99, ISSUE 9, P1699-1709, September 2018

Practice Guideline Update Recommendations Summary: Disorders of Consciousness

Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology; the American Congress of Rehabilitation Medicine; and the National Institute on Disability, Independent Living, and Rehabilitation Research
Published:August 08, 2018DOI:https://doi.org/10.1016/j.apmr.2018.07.001

      Abstract

      Objective

      To update the 1995 American Academy of Neurology (AAN) practice parameter on persistent vegetative state and the 2002 case definition on minimally conscious state (MCS) and provide care recommendations for patients with prolonged disorders of consciousness (DoC).

      Methods

      Recommendations were based on systematic review evidence, related evidence, care principles, and inferences using a modified Delphi consensus process according to the AAN 2011 process manual, as amended.

      Recommendations

      Clinicians should identify and treat confounding conditions, optimize arousal, and perform serial standardized assessments to improve diagnostic accuracy in adults and children with prolonged DoC (Level B). Clinicians should counsel families that for adults, MCS (vs vegetative state [VS]/ unresponsive wakefulness syndrome [UWS]) and traumatic (vs nontraumatic) etiology are associated with more favorable outcomes (Level B). When prognosis is poor, long-term care must be discussed (Level A), acknowledging that prognosis is not universally poor (Level B). Structural MRI, SPECT, and the Coma Recovery Scale–Revised can assist prognostication in adults (Level B); no tests are shown to improve prognostic accuracy in children. Pain always should be assessed and treated (Level B) and evidence supporting treatment approaches discussed (Level B). Clinicians should prescribe amantadine (100–200 mg bid) for adults with traumatic VS/UWS or MCS (4–16 weeks post injury) to hasten functional recovery and reduce disability early in recovery (Level B). Family counseling concerning children should acknowledge that natural history of recovery, prognosis, and treatment are not established (Level B). Recent evidence indicates that the term chronic VS/UWS should replace permanent VS, with duration specified (Level B). Additional recommendations are included.

      List of abbreviations:

      AAN (American Academy of Neurology), ACRM (American Congress of Rehabilitation Medicine), CI (confidence interval), CRS-R (Coma Recovery Scale–Revised), DoC (disorders of consciousness), DRS (Disability Rating Scale), FDG (fluorodeoxyglucose), MCS (minimally conscious state), TBI (traumatic brain injury), UWS (unresponsive wakefulness syndrome), VS (vegetative state)
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      References

      1. Giacino JT, Katz DI, Schiff ND, et al; for the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Comprehensive systematic review update summary: disorders of consciousness: report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology; the American Congress of Rehabilitation Medicine; and the National Institute on Disability, Independent Living, and Rehabilitation Research. Neurology Epub 2018 Aug 8.

        • Andrews K.
        • Murphy L.
        • Munday R.
        • Littlewood C.
        Misdiagnosis of the vegetative state: retrospective study in a rehabilitation unit.
        BMJ. 1996; 313: 13-16
        • Lovstad M.
        • Froslie K.F.
        • Giacino J.T.
        • Skandsen T.
        • Anke A.
        • Schanke A.K.
        Reliability and diagnostic characteristics of the JFK Coma Recovery Scale–revised: exploring the influence of rater’s level of experience.
        J Head Trauma Rehabil. 2010; 25: 349-356
        • Turgeon A.F.
        • Lauzier F.
        • Simard J.F.
        • et al.
        • for the Canadian Critical Care Trials Group
        Mortality associated with withdrawal of life-sustaining therapy for patients with severe traumatic brain injury: a Canadian multicentre cohort study.
        CMAJ. 2011; 183: 1581-1588
        • Whyte J.
        • Nordenbo A.M.
        • Kalmar K.
        • et al.
        Medical complications during inpatient rehabilitation among patients with traumatic disorders of consciousness.
        Arch Phys Med Rehabil. 2013; 94: 1877-1883
        • Davidson G.H.
        • Hamlat C.A.
        • Rivara F.P.
        • Koepsell T.D.
        • Jurkovich G.J.
        • Arbabi S.
        Long-term survival of adult trauma patients.
        JAMA. 2011; 305: 1001-1007
        • Cortese M.D.
        • Riganello F.
        • Arcuri F.
        • et al.
        Coma Recovery Scale–R: variability in the disorder of consciousness.
        BMC Neurol. 2015; 15: 186
        • Candelieri A.
        • Cortese M.D.
        • Dolce G.
        • Riganello F.
        • Sannita W.G.
        Visual pursuit: within-day variability in the severe disorder of consciousness.
        J Neurotrauma. 2011; 28: 2013-2017
        • Bardin J.C.
        • Fins J.J.
        • Katz D.I.
        • et al.
        Dissociations between behavioural and functional magnetic resonance imaging-based evaluations of cognitive function after brain injury.
        Brain. 2011; 134: 769-782
        • Schnakers C.
        • Zasler N.
        Assessment and management of pain in patients with disorders of consciousness.
        PM R. 2015; 7: S270-S277
        • Majerus S.
        • Gill-Thwaites H.
        • Andrews K.
        • Laureys S.
        Behavioral evaluation of consciousness in severe brain damage.
        Prog Brain Res. 2005; 150: 397-413
        • Schnakers C.
        • Vanhaudenhuyse A.
        • Giacino J.
        • et al.
        Diagnostic accuracy of the vegetative and minimally conscious state: clinical consensus versus standardized neurobehavioral assessment.
        BMC Neurol. 2009; 9: 35
        • Childs N.L.
        • Mercer W.N.
        • Childs H.W.
        Accuracy of diagnosis of persistent vegetative state.
        Neurology. 1993; 43: 1465-1467
        • Smart C.M.
        • Giacino J.T.
        • Cullen T.
        • et al.
        A case of locked-in syndrome complicated by central deafness.
        Nat Clin Pract Neurol. 2008; 4: 448-453
        • Laureys S.
        • Pellas F.
        • Van Eeckhout P.
        • et al.
        The locked-in syndrome: what is it like to be conscious but paralyzed and voiceless?.
        Prog Brain Res. 2005; 150: 495-511
        • Giacino J.T.
        • Kalmar K.
        • Whyte J.
        The JFK Coma Recovery Scale–Revised: measurement characteristics and diagnostic utility.
        Arch Phys Med Rehabil. 2004; 85: 2020-2029
        • Seel R.T.
        • Sherer M.
        • Whyte J.
        • et al.
        Assessment scales for disorders of consciousness: evidence-based recommendations for clinical practice and research.
        Arch Phys Med Rehabil. 2010; 91: 1795-1813
        • Whyte J.
        • DiPasquale M.C.
        • Vaccaro M.
        Assessment of command-following in minimally conscious brain injured patients.
        Arch Phys Med Rehabil. 1999; 80: 653-660
        • Shiel A.
        • Horn S.A.
        • Wilson B.A.
        • Watson M.J.
        • Campbell M.J.
        • McLellan D.L.
        The Wessex Head Injury Matrix (WHIM) main scale: a preliminary report on a scale to assess and monitor patient recovery after severe head injury.
        Clin Rehabil. 2000; 14: 408-416
        • Gill-Thwaites H.
        • Munday R.
        The Sensory Modality Assessment Rehabilitation Technique (SMART): a valid and reliable assessment for the vegetative and minimally conscious state patient.
        Brain Inj. 2004; 18: 1255-1269
        • Ansell B.J.
        • Keenan J.E.
        The Western Neuro Sensory Stimulation Profile: a tool for assessing slow-to-recover head-injured patients.
        Arch Phys Med Rehabil. 1989; 70: 104-108
        • Pape T.L.
        • Heinemann A.W.
        • Kelly J.P.
        • Hurder A.G.
        • Lundgren S.
        A measure of neurobehavioral functioning after coma. Part I: theory, reliability, and validity of Disorders of Consciousness Scale.
        J Rehabil Res Dev. 2005; 42: 1-17
        • Rader M.A.
        • Ellis D.W.
        The Sensory Stimulation Assessment Measure (SSAM): a tool for early evaluation of severely brain-injured patients.
        Brain Inj. 1994; 8: 309-321
        • Monti M.M.
        • Rosenberg M.
        • Finoia P.
        • Kamau E.
        • Pickard J.D.
        • Owen A.M.
        Thalamofrontal connectivity mediates top-down cognitive functions in disorders of consciousness.
        Neurology. 2015; 84: 167-173
        • Kotchoubey B.
        • Yu T.
        • Mueller F.
        • Vogel D.
        • Veser S.
        • Lang S.
        True or false? Activations of language-related areas in patients with disorders of consciousness.
        Curr Pharm Des. 2014; 20: 4239-4247
        • Stender J.
        • Gosseries O.
        • Bruno M.A.
        • et al.
        Diagnostic precision of PET imaging and functional MRI in disorders of consciousness: a clinical validation study.
        Lancet. 2014; 384: 514-522
        • Sitt J.D.
        • King J.R.
        • El Karoui I.
        • et al.
        Large scale screening of neural signatures of consciousness in patients in a vegetative or minimally conscious state.
        Brain. 2014; 137: 2258-2270
        • Nakase-Richardson R.
        • Whyte J.
        • Giacino J.T.
        • et al.
        Longitudinal outcome of patients with disordered consciousness in the NIDRR TBI Model Systems Programs.
        J Neurotrauma. 2012; 29: 59-65
        • Katz D.I.
        • Polyak M.
        • Coughlan D.
        • Nichols M.
        • Roche A.
        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.
        Prog Brain Res. 2009; 177: 73-88
        • Riganello F.
        • Cortese M.D.
        • Dolce G.
        • Lucca L.F.
        • Sannita W.G.
        The autonomic system functional state predicts responsiveness in disorder of consciousness.
        J Neurotrauma. 2015; 32: 1071-1077
        • Ashwal S.
        • Cranford R.
        • Bernat J.L.
        • et al.
        Medical aspects of the persistent vegetative state: (First of two parts).
        N Engl J Med. 1994; 330: 1499-1508
        • Childs N.L.
        • Mercer W.N.
        Brief report: late improvement in consciousness after posttraumatic vegetative state.
        N Engl J Med. 1996; 334: 24-25
        • Marshall L.F.
        • Becker D.P.
        • Bowers S.A.
        • et al.
        The National Traumatic Coma Data Bank: part 1: design, purpose, goals, and results.
        J Neurosurg. 1983; 59: 276-284
        • Luaute J.
        • Maucort-Boulch D.
        • Tell L.
        • et al.
        Long-term outcomes of chronic minimally conscious and vegetative states.
        Neurology. 2010; 75: 246-252
        • Estraneo A.
        • Moretta P.
        • Loreto V.
        • et al.
        Predictors of recovery of responsiveness in prolonged anoxic vegetative state.
        Neurology. 2013; 80: 464-470
        • Estraneo A.
        • Moretta P.
        • Loreto V.
        • Lanzillo B.
        • Santoro L.
        • Trojano L.
        Late recovery after traumatic, anoxic, or hemorrhagic long-lasting vegetative state.
        Neurology. 2010; 75: 239-245
        • Whyte J.
        • Nakase-Richardson R.
        Disorders of consciousness: outcomes, comorbidities, and care needs.
        Arch Phys Med Rehabil. 2013; 94: 1851-1854
        • Giacino J.T.
        • Kalmar K.
        The vegetative and minimally conscious states: a comparison of clinical features and functional outcome.
        J Head Trauma Rehabil. 1997; 12: 36-51
        • Ganesh S.
        • Guernon A.
        • Chalcraft L.
        • Harton B.
        • Smith B.
        • Louise-Bender Pape T.
        Medical comorbidities in disorders of consciousness patients and their association with functional outcomes.
        Arch Phys Med Rehabil. 2013; 94: 1899-1907
        • Nakase-Richardson R.
        • McNamee S.
        • Howe L.L.
        • et al.
        Descriptive characteristics and rehabilitation outcomes in active duty military personnel and veterans with disorders of consciousness with combat- and noncombat-related brain injury.
        Arch Phys Med Rehabil. 2013; 94: 1861-1869