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CURRENT ADVANCES IN ASSESSMENT AND MANAGEMENT OF PATIENTS IN LOW LEVEL NEUROLOGICAL STATES THIRD ANNUAL PACIFIC NORTHWEST BRAIN INJURY CONFERENCE. NATHAN D. ZASLER, MD CEO & MEDICAL DIRECTOR, CONCUSSION CARE CENTRE OF VIRGINIA AND TREE OF LIFE SERVICES CLINICAL PROF., DEPT. OF PM&R, VCU
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CURRENT ADVANCES IN ASSESSMENT AND MANAGEMENT OF PATIENTS IN LOW LEVEL NEUROLOGICAL STATESTHIRD ANNUAL PACIFIC NORTHWESTBRAIN INJURY CONFERENCE NATHAN D. ZASLER, MD CEO & MEDICAL DIRECTOR, CONCUSSION CARE CENTRE OF VIRGINIA AND TREE OF LIFE SERVICES CLINICAL PROF., DEPT. OF PM&R, VCU CLINICAL ASSOC. PROF., DEPT. OF PM&R, UVA
INTRODUCTION • CHALLENGES IN DX. AND TX. • INCONSISTENCY IN NOMENCLATURE USE AND UNDERSTANDING • CONFUSION REGARDING PROGNOSTICATION • GUIDELINE DEVELOPMENT ISSUES • CURRENT RECOMMENDATIONS – ANBICS • RECENT RESEARCH DEVELOPMENTS • FUTURE DIRECTIONS FOR RESEARCH
CLARIFICATION OF TERMINOLOGY • COMA • VEGETATIVE STATE • PVS - PERSISTENT VS. PERMANENT • MINIMALLY CONSCIOUS STATE (MCS) • AKINETIC MUTISM • LOCKED IN SYNDROME
COMA • STATE OF UNAROUSABLE UNRESPONSIVENESS • TYPICALLY EYES CLOSED - NO SLEEP WAKE CYCLES • DO NOT FOLLOW COMMANDS • NO GOAL DIRECTED BEHAVIOR • NO VERBALIZATION • NO SUSTAINED VISUAL PURSUIT
VEGETATIVE STATE • AROUSAL WITHOUT AWARENESS • PERIODS OF EYE OPENING • SUBCORTICAL RESPONSES SEEN • SLEEP WAKE CYCLES PRESENT • DIAGNOSIS ONLY MADE BY SERIAL NEUROBEHAVIORAL EXAM • LIMITS OF ASSESSING INTERNAL AWARENESS
MINIMALLY CONSCIOUS STATE • PRIMITIVE NEUROBEHAVIORAL RESPONSES SEEN - SUB-CORTICAL • EVIDENCE OF SOME LEVEL OF AWARENESS TO STIMULI • MUST LOOK AT FREQUENCY AND CONTEXT OF RESPONSES • INCONSISTENT RESPONSES THAT DO NOT REACH THRESHOLD FOR RELIABLE AND/OR CONSISTENT COMMUNICATION • AKINETIC MUTISM - MCS SUBSET
AKINETIC MUTISM • MINIMAL DEGREE OF MOVEMENT AND SPEECH • DA SYSTEM INVOLVEMENT • TYPICALLY + EYE OPENING AND TRACKING • PATIENTS TYPICALLY IMPROVE WITH DOPAMNE AGONIST TX.
LOCKED IN SYNDROME • AWARENESS RELATIVELY WELL PRESERVED • ANARTHRIA AND QUADRIPLEGIA • VENTRAL PONTINE LESION • VERTICAL EYE MOVEMENTS AND BLINK TYPICALLY PRESERVED • LOWER CRANIAL NERVE AND SWC DYSFUNCTION COMMONLY SEEN
TRANSITION FROM COMA TO VEGETATIVE STATE • EYE OPENING • FADING OF DECEREBRATE REACTIONS • RETURN OF SLEEP WAKE CYCLES • EMERGENCE OF SUB-CORTICAL RESPONSES • CONTROVERSY ON: VISUAL TRACKING, DISCRETE MOTOR LOCALIZATION AND EMOTIONAL RESPONSES - VS OR MCS?
VS AND MCS • DIFFERENTIAL DIAGNOSTIC ISSUES: ? HIGH RATE OF MISDIAGNOSIS • PROGNOSTICATION ISSUES: EARLY VS. LATE PARAMETERS • PAIN PERCEPTION: WHAT DO WE REALLY KNOW?
LANDMARK PUBLICATIONS • AAN POSITION PAPERS - 1989 • AMA COUNCIL REPORT - 1990 • MSTF POSITION PAPER - 1994 • ACRM POSITION PAPER - 1995 • AAN PRACTICE PARAMETER - 1995 • INT. WORKING PARTY - 1996 • ANBICS - IN PROGRESS
EMERGENCE FROM VS • MUST DIFFERENTIATE BETWEEN SIGNS THAT ARE PART AND PARCEL OF VS AND SIGNS THAT INDICATE EMERGENT AWARENESS • TIME COURSE FOR EMERGENCE IS VARIABLE BUT GENERALLY CORRELATES WITH LEVEL OF FUNCTIONAL DISABILITY • PERMANENT VEGETATIVE STATE CRITERIA • RECOVERY AFTER “PERMANENCY”
PREDICTING OUTCOME IN SEVERE TBI • EARLY PREDICTORS - GCS, IMAGING (S VS. D), MMEPs (INCLUDING LAPs AND ERPs), RISK FACTORS FOR SECONDARY BI, EEG, AGE • LATE PREDICTORS - PRETTY MUCH ALL THE EARLY ONES WITH PARTICULAR EMPHASIS ON SECONDARY BI AND MMEPs. PLUS DURATION OF VS. • MULTIFACTORIAL REGRESSION ANALYSIS FOR OUTCOME PREDICTION • DURATION OF VS MUCH MORE TIED TO LIKELIHOOD OF IMPROVEMENT THAN DURATION OF MCS
NEUROREHABILITATIVE CARE FOR VS/MCS • ORTHOTICS AND SEATING • FAMILY EDUCATION AND TRAINING • TREAT NEUROMEDICAL FACTORS MASKING RECOVERY • TREAT NEUROMEDICAL ISSUES ASSOCIATED WITH CONDITION • AVOID IATROGENIC COMPLICATIONS • NUTRITIONAL MANAGMENT • PREVENT MORBIDITY • RESPIRATORY MANAGEMENT
ADDRESS POTENTIAL FACTORS MASKING RECOVERY • PTE • LATE INTRACRANIAL PATHOLOGY • PTCH • NEUROENDOCRINE DYSFUNCTION • OCCULT INFECTION • ELECTROLYTE IMBALANCE
TREAT NEUROMEDICAL ISSUES SEEN IN LLNS • CENTRAL DYSAUTONOMIA • NHO • ALTERATIONS IN SLEEP WAKE CYCLE • TONAL ALTERATION • RARE SEQUELAE
AVOID IATROGENIC COMPLICATIONS • DRUGS • ELECTROLYTE IMBALANCES • UNDER- VS. OVER-STIMULATION
NUTRITIONAL MANAGEMENT • ENTERAL FEEDINGS • LONG TERM NUTRITIONAL ISSUES
PREVENTION OF MORBIDITY • CONTRACTURES • SKIN BREAKDOWN • INFECTION CONTROL • IMMOBILIZATION • PULMONARY TOILET • DECANNULATE AS POSSIBLE
FAMILY EDUCATION AND TRAINING • PURPOSE OF EDUCATION • OPPORTUNITIES TO TRY AND CARE FOR PATIENT AT HOME - SHOULD THEY BE ENCOURAGED/ • SHOULD ALL FAMILIES TAKE ON HOME CARE? WHAT IS OUR RESPONSIBILITY AS CLINICIANS?
FUNCTIONAL ASSESSMENT • CRITICAL FOR PROPER BEHAVIORAL TRACKING AND ASSESSMENT OF VS & MCS • VARIOUS BATTERIES AVAILABLE: • DRS SSAM • CNC RLAS • WNSSP CRS • SMART
COMA STIMULATION • TRADITIONALLY MEANT TO IMPLY STRUCTURED SENSORY STIMULATION • PHARMACOTHERAPY & NEURAL STIMULATION? • SENSORY REGULATION • SCIENTIFIC EVIDENCE OF BENEFIT
PHARMACOTHERAPY FOR VS AND MCS • IN PERSONS IN VS, NO EVIDENCE THAT MEDICATIONS ALTER RATE OF RECOVERY OR EVENTUAL PLATEAU. • IN PERSONS IN MCS, MEDICATIONS MAY HELP AROUSAL AND BRADYKINESIA. • NEURAL RECOVERY FACILITATORS VS. INHIBITORS. • TREATMENT REMAINS VERY MUCH EMPIRICAL AT PRESENT; HOWEVER, BEST EVIDENCE IS FOR PRO-DOPAMINERGIC AGENTS IN FACILITATION OF NEURORECOVERY.
NEUROSTIMULATION • DORSAL COLUMN STIMULATION • THALAMIC STIMULATION • PERIPHERAL NERVE (SOMATOSENSORY) STIMULATION
VARIABLE IN ERMPs • LENGTH OF STAY • THERAPIST EXPERTISE • PHYSICIAN EXPERTISE • ACCESS TO NEURODIAGNOSTIC FACILITIES • METHODS FOR OUTCOME TRACKING • ADMISSION/DISCHARGE CRITERIA
GUIDELINE DEVELOPMENT ISSUES • GENERAL PURPOSE OF PRACTICE GUIDELINES: DEVELOP STRATEGIES FOR PATIENT MANAGEMENT TO ASSIST IN CLINICAL DECISION MAKING • UTILIZES AN EXPLICIT RATHER THAN IMPLICIT APPROACH
CLASSIFICATION OF EVIDENCE • CLASS I - BASED ON PROSPECTIVE, RANDOMIZED, CONTROLLED STUDIES • CLASS II - PROSPECTIVE DATA COLLECTION STUDIES AS WELL AS RELIABLE RETROSPECTIVE DATA ANALYSES (COHORT, CASE CONTROL, PREVALENCE AND OBSERVATIONAL STUDIES). • CLASS III - RETROSPECTIVE DATA ANALYSIS (UNCONTROLLED CLINICAL SERIES, DATA BASES, CASE REPORTS & EXPERT OPINION).
MORE ON GUIDELINES • STANDARDS ARE BASED ON CLASS I EVIDENCE • PRACTICE GUIDELINES ARE BASED PRIMARILY ON CLASS II EVIDENCE • OPTIONS FOR MANAGEMENT ARE BASED ON CLASS III EVIDENCE • REFLECT: HIGH, MODERATE, LOW CLINICAL CERTAINTY, RESPECTIVELY
CURRENT RECOMMENDATIONS • APPROPRIATE AND PREREQUISITE INTERVENTIONS • DECREASE MORBIDITY • MEDICAL MANAGEMENT • SUPPLEMENTAL INTERVENTIONS - ONCE VS IS PERMANENT NO LONGER SUPPORTED: • SENSORY STIMULATION/REGULATION • PHARMACOLOGIC INTERVENTIONS
APPROPRIATE AND PREREQUISIT INTERVENTIONS • ROM EXERCISES • POSITIONING PROTOCOLS • BOWEL & BLADDER REGIMENS • DIETARY MANAGEMENT • ADDRESS TONAL ALTERATIONS • MANAGE NHO • MANAGE CENTRAL DYSAUTONOMIA • PROTOCOL FOR DECANNULATION • TREAT REVERSIBLE MEDICAL CONDITIONS • SKIN CARE
OTHER RECOMMENDATIONS • PROMOTE ALERTNESS, INCREASE COMMUNICATION ABILITY AND ALLEVIATE PAIN/SUFFERING IN PERSONS IN MCS • ADMINISTRATION/WITHDRAWAL DETERMINATIONS TO BE MADE BY MD IN CONSULTATION WITH FAMILY/GUARDIAN (LIVING WILL ISSUES) • SETTING MUST BE ABLE TO PROVIDE RECOMMENDED TREATMENTS • DIAGNOSIS AND CONSULTATION BY SPECIALIZED M.D.
ADMINISTRATION AND WITHDRAWAL ISSUES • MEDICATIONS AND OTHER COMMONLY ORDERED TREATMENTS • SUPPLEMENTAL OXYGEN AND ANTIBIOTICS • COMPLEX ORGAN SUSTAINING TREATMENTS - E.G. DIALYSIS • ADMINISTRATION OF BLOOD PRODUCTS • ARTIFICIAL HYDRATION AND NUTRITION
LONG TERM CARE ISSUES • REASSESSMENT SHOULD OCCUR AT 3, 6, & 12 MONTHS AFTER DETERMINATION OF PERMANENCE • ONCE VS IS PERMANENT - DNR ORDER IS APPROPRIATE (MAY BE MADE EARLIER)
ISSUES AND CONTROVERSIES • ANALYSIS OF DATA AND LIMITATIONS • LIFE EXPECTANCY • EMERGENCE FROM VS • MCS - A NEW TERM AND PATIENT CATEGORY - LITTLE DATA • GRAY ZONE BETWEEN VS & MCS • CONFLICT RESOLUTION & CROSS DISCIPLINARY CONSENSUS • PAIN AND SUFFERING IN VS AND MCS
RECENT RESEARCH DEVELOPMENTS • FUNCTIONAL VS – PATIENTS MAY APPEAR VS BUT ACTUALLY BE MCS • LIKELY ARE WIDE VARIATIONS IN BRAIN METABOLISM IN VS WITH SOME CEREBRAL REGIONS RETAINING PARTIAL FUNCTION • NOCICEPTIVE STIMULI MAY PRODUCE INCREASED BRAIN ACTIVITY IN PRIMARY SOMATOSENSORY CORTEX IN VS – DISASSOCIATED WITH HIGHER ORDER ASSOCIATIVE CORTEX ACTIVATION
RECENT RESEARCH DEVELOPMENTS • IN A SUBPOPULATION OF VS PATIENTS, THERE IS PRESERVATION OF THALAMOCORTICAL FEEDBACK CONNECTIONS THAT ALLOW FOR CORTICAL INFORMATION PROCESSING AND MAY EVEN INVOLVE SEMANTIC LEVELS OF PROCESSING • RECOVERY OF CONSCIOUSNESS APPEARS TO BE ASSOCIATED WITH RESTORATION OF CORTICOTHALAMOCORTICAL INTERACTION • SOME MCS PATIENTS MAY RETAIN WIDELY DISTRIBUTED CORTICAL SYSTEMS WITH POTENTIAL FOR COGNITIVE AND SENSORY FUNCTION DESPITE THEIR INABILITY TO FOLLOW SIMPLE COMMANDS OR RELIABLY COMMUNICATE
FUTURE DIRECTIONS FOR RESEARCH • INCIDENCE AND PREVALENCE OF VS AND MCS IN TBI • NATURAL HISTORY, RECOVERY COURSE AND LONG TERM OUTCOME • LEVELS OF CERTAINTY ASSOCIATED WITH PREDICTORS OF RECOVERY • UTILITY OF ASSESSMENT METHODS • TREATMENT EFFICACY • IMPACT OF OPTION DISSEMINATION • EXAMINATION OF FAMILY BELIEFS AND RELATION TO OUTCOME/UTILIZATION
WATCH FOR: • “BRAIN INJURY MEDICINE: PRINCIPLES AND PRACTICE” • EDITED BY N. ZASLER, D. KATZ AND R. ZAFONTE • CORE TEXTBOOK ON TBI ASSESSMENT AND MANAGEMENT • OVER 60 CHAPTERS WRITTEN BY INTERNATIONAL LEADERS IN THE FIELD • PUBLISHED BY DEMOS PUBLICATIONS - NY, NY • EXPECTED DATE OF PUBLICATION IS EARLY 2006