CURRENT ADVANCES IN ASSESSMENT AND MANAGEMENT OF PATIENTS IN LOW LEVEL NEUROLOGICAL STATES THIRD ANNUAL PACIFIC NORTHWEST BRAIN INJURY CONFERENCE - PowerPoint PPT Presentation

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CURRENT ADVANCES IN ASSESSMENT AND MANAGEMENT OF PATIENTS IN LOW LEVEL NEUROLOGICAL STATES THIRD ANNUAL PACIFIC NORTHWEST BRAIN INJURY CONFERENCE

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Title: CURRENT ADVANCES IN ASSESSMENT AND MANAGEMENT OF PATIENTS IN LOW LEVEL NEUROLOGICAL STATES THIRD ANNUAL PACIFIC NORTHWEST BRAIN INJURY CONFERENCE


1
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 PMR, VCU
  • CLINICAL ASSOC. PROF., DEPT. OF PMR, UVA

2
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

3
CLARIFICATION OF TERMINOLOGY
  • COMA
  • VEGETATIVE STATE
  • PVS - PERSISTENT VS. PERMANENT
  • MINIMALLY CONSCIOUS STATE (MCS)
  • AKINETIC MUTISM
  • LOCKED IN SYNDROME

4
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

5
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

6
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

7
AKINETIC MUTISM
  • MINIMAL DEGREE OF MOVEMENT AND SPEECH
  • DA SYSTEM INVOLVEMENT
  • TYPICALLY EYE OPENING AND TRACKING
  • PATIENTS TYPICALLY IMPROVE WITH DOPAMNE AGONIST
    TX.

8
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

9
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?

10
VS AND MCS
  • DIFFERENTIAL DIAGNOSTIC ISSUES ? HIGH RATE OF
    MISDIAGNOSIS
  • PROGNOSTICATION ISSUES EARLY VS. LATE
    PARAMETERS
  • PAIN PERCEPTION WHAT DO WE REALLY KNOW?

11
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

12
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

13
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

14
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

15
ADDRESS POTENTIAL FACTORS MASKING RECOVERY
  • PTE
  • LATE INTRACRANIAL PATHOLOGY
  • PTCH
  • NEUROENDOCRINE DYSFUNCTION
  • OCCULT INFECTION
  • ELECTROLYTE IMBALANCE

16
TREAT NEUROMEDICAL ISSUES SEEN IN LLNS
  • CENTRAL DYSAUTONOMIA
  • NHO
  • ALTERATIONS IN SLEEP WAKE CYCLE
  • TONAL ALTERATION
  • RARE SEQUELAE

17
AVOID IATROGENIC COMPLICATIONS
  • DRUGS
  • ELECTROLYTE IMBALANCES
  • UNDER- VS. OVER-STIMULATION

18
NUTRITIONAL MANAGEMENT
  • ENTERAL FEEDINGS
  • LONG TERM NUTRITIONAL ISSUES

19
PREVENTION OF MORBIDITY
  • CONTRACTURES
  • SKIN BREAKDOWN
  • INFECTION CONTROL
  • IMMOBILIZATION
  • PULMONARY TOILET
  • DECANNULATE AS POSSIBLE

20
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?

21
FUNCTIONAL ASSESSMENT
  • CRITICAL FOR PROPER BEHAVIORAL TRACKING AND
    ASSESSMENT OF VS MCS
  • VARIOUS BATTERIES AVAILABLE
  • DRS SSAM
  • CNC RLAS
  • WNSSP CRS
  • SMART

22
COMA STIMULATION
  • TRADITIONALLY MEANT TO IMPLY STRUCTURED SENSORY
    STIMULATION
  • PHARMACOTHERAPY NEURAL STIMULATION?
  • SENSORY REGULATION
  • SCIENTIFIC EVIDENCE OF BENEFIT

23
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.

24
NEUROSTIMULATION
  • DORSAL COLUMN STIMULATION
  • THALAMIC STIMULATION
  • PERIPHERAL NERVE (SOMATOSENSORY) STIMULATION

25
VARIABLE IN ERMPs
  • LENGTH OF STAY
  • THERAPIST EXPERTISE
  • PHYSICIAN EXPERTISE
  • ACCESS TO NEURODIAGNOSTIC FACILITIES
  • METHODS FOR OUTCOME TRACKING
  • ADMISSION/DISCHARGE CRITERIA

26
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

27
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).

28
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

29
CURRENT RECOMMENDATIONS
  • APPROPRIATE AND PREREQUISITE INTERVENTIONS
  • DECREASE MORBIDITY
  • MEDICAL MANAGEMENT
  • SUPPLEMENTAL INTERVENTIONS - ONCE VS IS PERMANENT
    NO LONGER SUPPORTED
  • SENSORY STIMULATION/REGULATION
  • PHARMACOLOGIC INTERVENTIONS

30
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

31
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.

32
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

33
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)

34
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

35
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

36
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 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

37
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

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

39
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