Title: CURRENT ADVANCES IN ASSESSMENT AND MANAGEMENT OF PATIENTS IN LOW LEVEL NEUROLOGICAL STATES THIRD ANNUAL PACIFIC NORTHWEST BRAIN INJURY CONFERENCE
1CURRENT 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 PMR, VCU
- CLINICAL ASSOC. PROF., DEPT. OF PMR, UVA
2INTRODUCTION
- 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
3CLARIFICATION OF TERMINOLOGY
- COMA
- VEGETATIVE STATE
- PVS - PERSISTENT VS. PERMANENT
- MINIMALLY CONSCIOUS STATE (MCS)
- AKINETIC MUTISM
- LOCKED IN SYNDROME
4COMA
- 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
5VEGETATIVE 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
6MINIMALLY 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
7AKINETIC MUTISM
- MINIMAL DEGREE OF MOVEMENT AND SPEECH
- DA SYSTEM INVOLVEMENT
- TYPICALLY EYE OPENING AND TRACKING
- PATIENTS TYPICALLY IMPROVE WITH DOPAMNE AGONIST
TX.
8LOCKED 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
9TRANSITION 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?
10VS AND MCS
- DIFFERENTIAL DIAGNOSTIC ISSUES ? HIGH RATE OF
MISDIAGNOSIS - PROGNOSTICATION ISSUES EARLY VS. LATE
PARAMETERS - PAIN PERCEPTION WHAT DO WE REALLY KNOW?
11LANDMARK 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
12EMERGENCE 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
13PREDICTING 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
14NEUROREHABILITATIVE 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
15ADDRESS POTENTIAL FACTORS MASKING RECOVERY
- PTE
- LATE INTRACRANIAL PATHOLOGY
- PTCH
- NEUROENDOCRINE DYSFUNCTION
- OCCULT INFECTION
- ELECTROLYTE IMBALANCE
16TREAT NEUROMEDICAL ISSUES SEEN IN LLNS
- CENTRAL DYSAUTONOMIA
- NHO
- ALTERATIONS IN SLEEP WAKE CYCLE
- TONAL ALTERATION
- RARE SEQUELAE
17AVOID IATROGENIC COMPLICATIONS
- DRUGS
- ELECTROLYTE IMBALANCES
- UNDER- VS. OVER-STIMULATION
18NUTRITIONAL MANAGEMENT
- ENTERAL FEEDINGS
- LONG TERM NUTRITIONAL ISSUES
19PREVENTION OF MORBIDITY
- CONTRACTURES
- SKIN BREAKDOWN
- INFECTION CONTROL
- IMMOBILIZATION
- PULMONARY TOILET
- DECANNULATE AS POSSIBLE
20FAMILY 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?
21FUNCTIONAL ASSESSMENT
- CRITICAL FOR PROPER BEHAVIORAL TRACKING AND
ASSESSMENT OF VS MCS - VARIOUS BATTERIES AVAILABLE
- DRS SSAM
- CNC RLAS
- WNSSP CRS
- SMART
22COMA STIMULATION
- TRADITIONALLY MEANT TO IMPLY STRUCTURED SENSORY
STIMULATION - PHARMACOTHERAPY NEURAL STIMULATION?
- SENSORY REGULATION
- SCIENTIFIC EVIDENCE OF BENEFIT
23PHARMACOTHERAPY 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.
24NEUROSTIMULATION
- DORSAL COLUMN STIMULATION
- THALAMIC STIMULATION
- PERIPHERAL NERVE (SOMATOSENSORY) STIMULATION
25VARIABLE IN ERMPs
- LENGTH OF STAY
- THERAPIST EXPERTISE
- PHYSICIAN EXPERTISE
- ACCESS TO NEURODIAGNOSTIC FACILITIES
- METHODS FOR OUTCOME TRACKING
- ADMISSION/DISCHARGE CRITERIA
26GUIDELINE 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
27CLASSIFICATION 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).
28MORE 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
29CURRENT RECOMMENDATIONS
- APPROPRIATE AND PREREQUISITE INTERVENTIONS
- DECREASE MORBIDITY
- MEDICAL MANAGEMENT
- SUPPLEMENTAL INTERVENTIONS - ONCE VS IS PERMANENT
NO LONGER SUPPORTED - SENSORY STIMULATION/REGULATION
- PHARMACOLOGIC INTERVENTIONS
30APPROPRIATE 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
31OTHER 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.
32ADMINISTRATION 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
33LONG 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)
34ISSUES 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
35RECENT 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
36RECENT 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 CORTICOTHALAMOCORTI
CAL 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
37FUTURE 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
38 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
39QUESTIONS AND ANSWERS