Neurorehabilitation in Disorders of Consciousness

Abstract

Survivors of severe acquired brain injury often experience prolonged disturbance in consciousness following emergence from coma. Most individuals pass through the vegetative or minimally conscious states en route to eventual recovery of consciousness, although either condition may be permanent. Rehabilitation clinicians charged with the care of these patients face numerous challenges as there are many open questions concerning diagnostic and prognostic accuracy, the natural history of recovery, and the most effective approaches to prevent medical complications and facilitate functional recovery. The last 5 years have been witness to a marked increase in well-designed empirical investigations concerning the rehabilitation of patients with disorders of consciousness. In this article, the authors review recent evidence concerning key factors that influence the course of recovery, present a model of care designed to mitigate medical complications, describe a systematic approach to assessment, and review the effectiveness of treatment interventions utilized in the rehabilitation setting.

Deep brain stimulation for disorders of consciousness: Systematic review of cases and ethics

“…Giacino et al [31] stated that recovery from MCS was significantly more favorable than assumed, with considerable recovery even at long-term (5 years).…”

“…The interval (between the injury and the DBS implant) is important to take into consideration in order to avoid ambiguity between a spontaneous recovery and the effect of DBS. The [3,4,31,47]. The prognosis for MCS is much better compared to that of VS [47].…”

“…The papers state that one key driver to explore the therapeutic potential of DBS in patients with DoC stems from the fact that the care of these patients is often reported to be severely neglected [28]. The neglect of patients in DoC is partly translated into a lack of standardized healthcare that is specific for them [29][30][31], such as in-patient rehabilitation [31]. As these patients cannot communicate whether they are "in pain or emotional distress" [30], they are considered to be vulnerable [29,32], and a denial of their needs has been called "therapeutic nihilism" [28,30] or "societal neglect syndrome" [33].…”

“…Because the diagnosis relies on subtleties, it is often inaccurate [32]: according to some authors, diagnostic errors amount to up to 40% of cases [8,31]. Some of the patients that were diagnosed with PVS by Yamamoto et al were later reclassified by other authors as MCS [44,45].…”

“…It has also been suggested that diagnosis was sometimes altered on purpose, because the patient would have better access to healthcare facilities [30]. Alternatively, the CRS-R could be seen as a good standard tool for the diagnosis of (P)VS and MCS [11,31]. To distinguish between (P)VS and MCS is important when assessing the potential effect of DBS treatment, because in these two conditions the likelihood on a spontaneous recovery differs, as discussed below.…”