Chapter Fifteen Neurological Disorders. CHAPTER 15 NEUROLOGICAL DISORDERS.
CCCV CCCV CURRENT ADVANCES IN ASSESSMENT AND MANAGEMENT OF PATIENTS IN LOW LEVEL NEUROLOGICAL STATES...
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Transcript of CCCV CCCV CURRENT ADVANCES IN ASSESSMENT AND MANAGEMENT OF PATIENTS IN LOW LEVEL NEUROLOGICAL STATES...
CCCVCCCV
CURRENT ADVANCES IN CURRENT ADVANCES IN ASSESSMENT AND ASSESSMENT AND
MANAGEMENT OF PATIENTS MANAGEMENT OF PATIENTS IN LOW LEVEL IN LOW LEVEL
NEUROLOGICAL STATESNEUROLOGICAL STATES
THIRD ANNUAL PACIFIC NORTHWESTTHIRD ANNUAL PACIFIC NORTHWESTBRAIN INJURY CONFERENCEBRAIN INJURY CONFERENCE
NATHAN D. ZASLER, MDNATHAN D. ZASLER, MDCEO & MEDICAL DIRECTOR, CONCUSSION CEO & MEDICAL DIRECTOR, CONCUSSION
CARE CENTRE OF VIRGINIA AND TREE OF LIFE CARE CENTRE OF VIRGINIA AND TREE OF LIFE SERVICESSERVICES
CLINICAL PROF., DEPT. OF PM&R, VCUCLINICAL PROF., DEPT. OF PM&R, VCUCLINICAL ASSOC. PROF., DEPT. OF PM&R, CLINICAL ASSOC. PROF., DEPT. OF PM&R,
UVAUVA
INTRODUCTIONINTRODUCTION CHALLENGES IN DX. AND TX.CHALLENGES IN DX. AND TX. INCONSISTENCY IN NOMENCLATURE INCONSISTENCY IN NOMENCLATURE
USE AND UNDERSTANDINGUSE AND UNDERSTANDING CONFUSION REGARDING CONFUSION REGARDING
PROGNOSTICATIONPROGNOSTICATION GUIDELINE DEVELOPMENT ISSUESGUIDELINE DEVELOPMENT ISSUES CURRENT RECOMMENDATIONS – ANBICSCURRENT RECOMMENDATIONS – ANBICS RECENT RESEARCH DEVELOPMENTSRECENT RESEARCH DEVELOPMENTS FUTURE DIRECTIONS FOR RESEARCHFUTURE DIRECTIONS FOR RESEARCH
CLARIFICATION OF CLARIFICATION OF TERMINOLOGYTERMINOLOGY
COMACOMAVEGETATIVE STATEVEGETATIVE STATEPVS - PERSISTENT VS. PVS - PERSISTENT VS.
PERMANENTPERMANENTMINIMALLY CONSCIOUS STATE MINIMALLY CONSCIOUS STATE
(MCS)(MCS)AKINETIC MUTISMAKINETIC MUTISM
LOCKED IN SYNDROMELOCKED IN SYNDROME
COMACOMASTATE OF UNAROUSABLE STATE OF UNAROUSABLE
UNRESPONSIVENESSUNRESPONSIVENESSTYPICALLY EYES CLOSED - NO TYPICALLY EYES CLOSED - NO
SLEEP WAKE CYCLESSLEEP WAKE CYCLESDO NOT FOLLOW COMMANDSDO NOT FOLLOW COMMANDSNO GOAL DIRECTED BEHAVIORNO GOAL DIRECTED BEHAVIORNO VERBALIZATIONNO VERBALIZATIONNO SUSTAINED VISUAL PURSUITNO SUSTAINED VISUAL PURSUIT
VEGETATIVE STATEVEGETATIVE STATEAROUSAL WITHOUT AWARENESSAROUSAL WITHOUT AWARENESSPERIODS OF EYE OPENINGPERIODS OF EYE OPENINGSUBCORTICAL RESPONSES SEENSUBCORTICAL RESPONSES SEENSLEEP WAKE CYCLES PRESENTSLEEP WAKE CYCLES PRESENTDIAGNOSIS ONLY MADE BY SERIAL DIAGNOSIS ONLY MADE BY SERIAL
NEUROBEHAVIORAL EXAMNEUROBEHAVIORAL EXAMLIMITS OF ASSESSING INTERNAL LIMITS OF ASSESSING INTERNAL
AWARENESSAWARENESS
MINIMALLY MINIMALLY CONSCIOUS STATECONSCIOUS STATE
PRIMITIVE NEUROBEHAVIORAL PRIMITIVE NEUROBEHAVIORAL RESPONSES SEEN - SUB-CORTICALRESPONSES SEEN - SUB-CORTICAL
EVIDENCE OF SOME LEVEL OF EVIDENCE OF SOME LEVEL OF AWARENESS TO STIMULIAWARENESS TO STIMULI
MUST LOOK AT FREQUENCY AND MUST LOOK AT FREQUENCY AND CONTEXT OF RESPONSESCONTEXT OF RESPONSES
INCONSISTENT RESPONSES THAT DO INCONSISTENT RESPONSES THAT DO NOT REACH THRESHOLD FOR NOT REACH THRESHOLD FOR RELIABLE AND/OR CONSISTENT RELIABLE AND/OR CONSISTENT COMMUNICATIONCOMMUNICATION
AKINETIC MUTISM - MCS SUBSET AKINETIC MUTISM - MCS SUBSET
AKINETIC MUTISMAKINETIC MUTISMMINIMAL DEGREE OF MOVEMENT MINIMAL DEGREE OF MOVEMENT
AND SPEECHAND SPEECHDA SYSTEM INVOLVEMENTDA SYSTEM INVOLVEMENTTYPICALLY + EYE OPENING AND TYPICALLY + EYE OPENING AND
TRACKINGTRACKINGPATIENTS TYPICALLY IMPROVE PATIENTS TYPICALLY IMPROVE
WITH DOPAMNE AGONIST TX.WITH DOPAMNE AGONIST TX.
LOCKED IN SYNDROMELOCKED IN SYNDROMEAWARENESS RELATIVELY WELL AWARENESS RELATIVELY WELL
PRESERVEDPRESERVEDANARTHRIA AND QUADRIPLEGIAANARTHRIA AND QUADRIPLEGIAVENTRAL PONTINE LESIONVENTRAL PONTINE LESIONVERTICAL EYE MOVEMENTS AND VERTICAL EYE MOVEMENTS AND
BLINK TYPICALLY PRESERVEDBLINK TYPICALLY PRESERVEDLOWER CRANIAL NERVE AND SWC LOWER CRANIAL NERVE AND SWC
DYSFUNCTION COMMONLY SEENDYSFUNCTION COMMONLY SEEN
TRANSITION FROM COMA TO TRANSITION FROM COMA TO VEGETATIVE STATEVEGETATIVE STATE
EYE OPENINGEYE OPENING FADING OF DECEREBRATE REACTIONSFADING OF DECEREBRATE REACTIONS RETURN OF SLEEP WAKE CYCLESRETURN OF SLEEP WAKE CYCLES EMERGENCE OF SUB-CORTICAL EMERGENCE OF SUB-CORTICAL
RESPONSES RESPONSES CONTROVERSY ON: VISUAL CONTROVERSY ON: VISUAL
TRACKING, DISCRETE MOTOR TRACKING, DISCRETE MOTOR LOCALIZATION AND EMOTIONAL LOCALIZATION AND EMOTIONAL RESPONSES - VS OR MCS?RESPONSES - VS OR MCS?
VS AND MCSVS AND MCSDIFFERENTIAL DIAGNOSTIC DIFFERENTIAL DIAGNOSTIC
ISSUES: ? HIGH RATE OF ISSUES: ? HIGH RATE OF MISDIAGNOSISMISDIAGNOSIS
PROGNOSTICATION ISSUES: PROGNOSTICATION ISSUES: EARLY VS. LATE PARAMETERSEARLY VS. LATE PARAMETERS
PAIN PERCEPTION: WHAT DO WE PAIN PERCEPTION: WHAT DO WE REALLY KNOW?REALLY KNOW?
LANDMARK PUBLICATIONSLANDMARK PUBLICATIONSAAN POSITION PAPERS - 1989AAN POSITION PAPERS - 1989AMA COUNCIL REPORT - 1990AMA COUNCIL REPORT - 1990MSTF POSITION PAPER - 1994MSTF POSITION PAPER - 1994ACRM POSITION PAPER - 1995ACRM POSITION PAPER - 1995AAN PRACTICE PARAMETER - AAN PRACTICE PARAMETER -
19951995INT. WORKING PARTY - 1996INT. WORKING PARTY - 1996ANBICS - IN PROGRESSANBICS - IN PROGRESS
EMERGENCE FROM VSEMERGENCE FROM VS MUST DIFFERENTIATE BETWEEN MUST DIFFERENTIATE BETWEEN
SIGNS THAT ARE PART AND PARCEL SIGNS THAT ARE PART AND PARCEL OF VS AND SIGNS THAT INDICATE OF VS AND SIGNS THAT INDICATE EMERGENT AWARENESSEMERGENT AWARENESS
TIME COURSE FOR EMERGENCE IS TIME COURSE FOR EMERGENCE IS VARIABLE BUT GENERALLY VARIABLE BUT GENERALLY CORRELATES WITH LEVEL OF CORRELATES WITH LEVEL OF FUNCTIONAL DISABILITYFUNCTIONAL DISABILITY
PERMANENT VEGETATIVE STATE PERMANENT VEGETATIVE STATE CRITERIACRITERIA
RECOVERY AFTER “PERMANENCY”RECOVERY AFTER “PERMANENCY”
PREDICTING OUTCOME IN PREDICTING OUTCOME IN SEVERE TBISEVERE TBI
EARLY PREDICTORS - GCS, IMAGING (S VS. EARLY PREDICTORS - GCS, IMAGING (S VS. D), MMEPs (INCLUDING LAPs AND ERPs), D), MMEPs (INCLUDING LAPs AND ERPs), RISK FACTORS FOR SECONDARY BI, EEG, RISK FACTORS FOR SECONDARY BI, EEG, AGEAGE
LATE PREDICTORS - PRETTY MUCH ALL THE LATE PREDICTORS - PRETTY MUCH ALL THE EARLY ONES WITH PARTICULAR EMPHASIS EARLY ONES WITH PARTICULAR EMPHASIS ON SECONDARY BI AND MMEPs. PLUS ON SECONDARY BI AND MMEPs. PLUS DURATION OF VS.DURATION OF VS.
MULTIFACTORIAL REGRESSION ANALYSIS MULTIFACTORIAL REGRESSION ANALYSIS FOR OUTCOME PREDICTION FOR OUTCOME PREDICTION
DURATION OF VS MUCH MORE TIED TO DURATION OF VS MUCH MORE TIED TO LIKELIHOOD OF IMPROVEMENT THAN LIKELIHOOD OF IMPROVEMENT THAN DURATION OF MCSDURATION OF MCS
NEUROREHABILITATIVE NEUROREHABILITATIVE CARE FOR VS/MCSCARE FOR VS/MCS
ORTHOTICS AND SEATINGORTHOTICS AND SEATING FAMILY EDUCATION AND TRAININGFAMILY EDUCATION AND TRAINING TREAT NEUROMEDICAL FACTORS MASKING TREAT NEUROMEDICAL FACTORS MASKING
RECOVERYRECOVERY TREAT NEUROMEDICAL ISSUES ASSOCIATED TREAT NEUROMEDICAL ISSUES ASSOCIATED
WITH CONDITIONWITH CONDITION AVOID IATROGENIC COMPLICATIONSAVOID IATROGENIC COMPLICATIONS NUTRITIONAL MANAGMENTNUTRITIONAL MANAGMENT PREVENT MORBIDITYPREVENT MORBIDITY RESPIRATORY MANAGEMENTRESPIRATORY MANAGEMENT
ADDRESS POTENTIAL FACTORS ADDRESS POTENTIAL FACTORS MASKING RECOVERYMASKING RECOVERY
PTEPTELATE INTRACRANIAL PATHOLOGYLATE INTRACRANIAL PATHOLOGYPTCHPTCHNEUROENDOCRINE DYSFUNCTIONNEUROENDOCRINE DYSFUNCTIONOCCULT INFECTIONOCCULT INFECTIONELECTROLYTE IMBALANCEELECTROLYTE IMBALANCE
TREAT NEUROMEDICAL TREAT NEUROMEDICAL ISSUES SEEN IN LLNSISSUES SEEN IN LLNS
CENTRAL DYSAUTONOMIACENTRAL DYSAUTONOMIANHONHOALTERATIONS IN SLEEP WAKE CYCLEALTERATIONS IN SLEEP WAKE CYCLETONAL ALTERATIONTONAL ALTERATIONRARE SEQUELAERARE SEQUELAE
AVOID IATROGENIC AVOID IATROGENIC COMPLICATIONSCOMPLICATIONS
DRUGSDRUGSELECTROLYTE IMBALANCESELECTROLYTE IMBALANCESUNDER- VS. OVER-STIMULATIONUNDER- VS. OVER-STIMULATION
NUTRITIONAL MANAGEMENTNUTRITIONAL MANAGEMENT
ENTERAL FEEDINGSENTERAL FEEDINGSLONG TERM NUTRITIONAL ISSUESLONG TERM NUTRITIONAL ISSUES
PREVENTION OF MORBIDITYPREVENTION OF MORBIDITY
CONTRACTURESCONTRACTURESSKIN BREAKDOWNSKIN BREAKDOWN INFECTION CONTROLINFECTION CONTROL IMMOBILIZATIONIMMOBILIZATIONPULMONARY TOILETPULMONARY TOILETDECANNULATE AS POSSIBLEDECANNULATE AS POSSIBLE
FAMILY EDUCATION AND FAMILY EDUCATION AND TRAININGTRAINING
PURPOSE OF EDUCATIONPURPOSE OF EDUCATIONOPPORTUNITIES TO TRY AND CARE OPPORTUNITIES TO TRY AND CARE
FOR PATIENT AT HOME - SHOULD FOR PATIENT AT HOME - SHOULD THEY BE ENCOURAGED/THEY BE ENCOURAGED/
SHOULD ALL FAMILIES TAKE ON SHOULD ALL FAMILIES TAKE ON HOME CARE? WHAT IS OUR HOME CARE? WHAT IS OUR RESPONSIBILITY AS CLINICIANS?RESPONSIBILITY AS CLINICIANS?
FUNCTIONAL ASSESSMENTFUNCTIONAL ASSESSMENTCRITICAL FOR PROPER CRITICAL FOR PROPER
BEHAVIORAL TRACKING AND BEHAVIORAL TRACKING AND ASSESSMENT OF VS & MCSASSESSMENT OF VS & MCS
VARIOUS BATTERIES AVAILABLE:VARIOUS BATTERIES AVAILABLE:DRSDRS SSAMSSAMCNCCNC RLASRLASWNSSPWNSSP CRSCRSSMARTSMART
COMA STIMULATIONCOMA STIMULATIONTRADITIONALLY MEANT TO TRADITIONALLY MEANT TO
IMPLY STRUCTURED SENSORY IMPLY STRUCTURED SENSORY STIMULATIONSTIMULATION
PHARMACOTHERAPY & NEURAL PHARMACOTHERAPY & NEURAL STIMULATION?STIMULATION?
SENSORY REGULATIONSENSORY REGULATIONSCIENTIFIC EVIDENCE OF SCIENTIFIC EVIDENCE OF
BENEFITBENEFIT
PHARMACOTHERAPY FOR VS PHARMACOTHERAPY FOR VS AND MCSAND MCS
IN PERSONS IN VS, NO EVIDENCE THAT IN PERSONS IN VS, NO EVIDENCE THAT MEDICATIONS ALTER RATE OF MEDICATIONS ALTER RATE OF RECOVERY OR EVENTUAL PLATEAU.RECOVERY OR EVENTUAL PLATEAU.
IN PERSONS IN MCS, MEDICATIONS IN PERSONS IN MCS, MEDICATIONS MAY HELP AROUSAL AND MAY HELP AROUSAL AND BRADYKINESIA. BRADYKINESIA.
NEURAL RECOVERY FACILITATORS VS. NEURAL RECOVERY FACILITATORS VS. INHIBITORS.INHIBITORS.
TREATMENT REMAINS VERY MUCH TREATMENT REMAINS VERY MUCH EMPIRICAL AT PRESENT; HOWEVER, EMPIRICAL AT PRESENT; HOWEVER, BEST EVIDENCE IS FOR PRO-BEST EVIDENCE IS FOR PRO-DOPAMINERGIC AGENTS IN DOPAMINERGIC AGENTS IN FACILITATION OF NEURORECOVERY.FACILITATION OF NEURORECOVERY.
NEUROSTIMULATIONNEUROSTIMULATIONDORSAL COLUMN STIMULATIONDORSAL COLUMN STIMULATIONTHALAMIC STIMULATIONTHALAMIC STIMULATIONPERIPHERAL NERVE PERIPHERAL NERVE
(SOMATOSENSORY) (SOMATOSENSORY) STIMULATIONSTIMULATION
VARIABLE IN ERMPsVARIABLE IN ERMPsLENGTH OF STAYLENGTH OF STAYTHERAPIST EXPERTISETHERAPIST EXPERTISEPHYSICIAN EXPERTISEPHYSICIAN EXPERTISEACCESS TO NEURODIAGNOSTIC ACCESS TO NEURODIAGNOSTIC
FACILITIESFACILITIESMETHODS FOR OUTCOME TRACKINGMETHODS FOR OUTCOME TRACKINGADMISSION/DISCHARGE CRITERIAADMISSION/DISCHARGE CRITERIA
GUIDELINE DEVELOPMENT GUIDELINE DEVELOPMENT ISSUESISSUES
GENERAL PURPOSE OF PRACTICE GENERAL PURPOSE OF PRACTICE GUIDELINES: DEVELOP STRATEGIES GUIDELINES: DEVELOP STRATEGIES FOR PATIENT MANAGEMENT TO FOR PATIENT MANAGEMENT TO ASSIST IN CLINICAL DECISION ASSIST IN CLINICAL DECISION MAKINGMAKING
UTILIZES AN EXPLICIT RATHER THAN UTILIZES AN EXPLICIT RATHER THAN IMPLICIT APPROACHIMPLICIT APPROACH
CLASSIFICATION OF CLASSIFICATION OF EVIDENCEEVIDENCE
CLASS I - BASED ON PROSPECTIVE, CLASS I - BASED ON PROSPECTIVE, RANDOMIZED, CONTROLLED STUDIESRANDOMIZED, CONTROLLED STUDIES
CLASS II - PROSPECTIVE DATA COLLECTION CLASS II - PROSPECTIVE DATA COLLECTION STUDIES AS WELL AS RELIABLE STUDIES AS WELL AS RELIABLE RETROSPECTIVE DATA ANALYSES (COHORT, RETROSPECTIVE DATA ANALYSES (COHORT, CASE CONTROL, PREVALENCE AND CASE CONTROL, PREVALENCE AND OBSERVATIONAL STUDIES).OBSERVATIONAL STUDIES).
CLASS III - RETROSPECTIVE DATA ANALYSIS CLASS III - RETROSPECTIVE DATA ANALYSIS (UNCONTROLLED CLINICAL SERIES, DATA (UNCONTROLLED CLINICAL SERIES, DATA BASES, CASE REPORTS & EXPERT OPINION).BASES, CASE REPORTS & EXPERT OPINION).
MORE ON GUIDELINESMORE ON GUIDELINES STANDARDS ARE BASED ON CLASS I STANDARDS ARE BASED ON CLASS I
EVIDENCEEVIDENCE PRACTICE GUIDELINES ARE BASED PRACTICE GUIDELINES ARE BASED
PRIMARILY ON CLASS II EVIDENCEPRIMARILY ON CLASS II EVIDENCE OPTIONS FOR MANAGEMENT ARE OPTIONS FOR MANAGEMENT ARE
BASED ON CLASS III EVIDENCEBASED ON CLASS III EVIDENCE REFLECT: HIGH, MODERATE, LOW REFLECT: HIGH, MODERATE, LOW
CLINICAL CERTAINTY, RESPECTIVELYCLINICAL CERTAINTY, RESPECTIVELY
CURRENT CURRENT RECOMMENDATIONSRECOMMENDATIONS
APPROPRIATE AND PREREQUISITE APPROPRIATE AND PREREQUISITE INTERVENTIONSINTERVENTIONS DECREASE MORBIDITYDECREASE MORBIDITY MEDICAL MANAGEMENTMEDICAL MANAGEMENT
SUPPLEMENTAL INTERVENTIONS - SUPPLEMENTAL INTERVENTIONS - ONCE VS IS PERMANENT NO LONGER ONCE VS IS PERMANENT NO LONGER SUPPORTED: SUPPORTED: SENSORY STIMULATION/REGULATIONSENSORY STIMULATION/REGULATION PHARMACOLOGIC INTERVENTIONSPHARMACOLOGIC INTERVENTIONS
APPROPRIATE AND PREREQUISIT APPROPRIATE AND PREREQUISIT INTERVENTIONSINTERVENTIONS
ROM EXERCISESROM EXERCISES POSITIONING PROTOCOLSPOSITIONING PROTOCOLS BOWEL & BLADDER REGIMENSBOWEL & BLADDER REGIMENS DIETARY MANAGEMENTDIETARY MANAGEMENT ADDRESS TONAL ALTERATIONSADDRESS TONAL ALTERATIONS MANAGE NHOMANAGE NHO MANAGE CENTRAL DYSAUTONOMIAMANAGE CENTRAL DYSAUTONOMIA PROTOCOL FOR DECANNULATIONPROTOCOL FOR DECANNULATION TREAT REVERSIBLE MEDICAL CONDITIONSTREAT REVERSIBLE MEDICAL CONDITIONS SKIN CARESKIN CARE
OTHER RECOMMENDATIONSOTHER RECOMMENDATIONS PROMOTE ALERTNESS, INCREASE PROMOTE ALERTNESS, INCREASE
COMMUNICATION ABILITY AND ALLEVIATE COMMUNICATION ABILITY AND ALLEVIATE PAIN/SUFFERING IN PERSONS IN MCSPAIN/SUFFERING IN PERSONS IN MCS
ADMINISTRATION/WITHDRAWAL ADMINISTRATION/WITHDRAWAL DETERMINATIONS TO BE MADE BY MD IN DETERMINATIONS TO BE MADE BY MD IN CONSULTATION WITH FAMILY/GUARDIAN CONSULTATION WITH FAMILY/GUARDIAN (LIVING WILL ISSUES)(LIVING WILL ISSUES)
SETTING MUST BE ABLE TO PROVIDE SETTING MUST BE ABLE TO PROVIDE RECOMMENDED TREATMENTSRECOMMENDED TREATMENTS
DIAGNOSIS AND CONSULTATION BY DIAGNOSIS AND CONSULTATION BY SPECIALIZED M.D. SPECIALIZED M.D.
ADMINISTRATION AND ADMINISTRATION AND WITHDRAWAL ISSUESWITHDRAWAL ISSUES
MEDICATIONS AND OTHER MEDICATIONS AND OTHER COMMONLY ORDERED TREATMENTSCOMMONLY ORDERED TREATMENTS
SUPPLEMENTAL OXYGEN AND SUPPLEMENTAL OXYGEN AND ANTIBIOTICSANTIBIOTICS
COMPLEX ORGAN SUSTAINING COMPLEX ORGAN SUSTAINING TREATMENTS - E.G. DIALYSISTREATMENTS - E.G. DIALYSIS
ADMINISTRATION OF BLOOD ADMINISTRATION OF BLOOD PRODUCTSPRODUCTS
ARTIFICIAL HYDRATION AND ARTIFICIAL HYDRATION AND NUTRITIONNUTRITION
LONG TERM CARE ISSUESLONG TERM CARE ISSUESREASSESSMENT SHOULD OCCUR REASSESSMENT SHOULD OCCUR
AT 3, 6, & 12 MONTHS AFTER AT 3, 6, & 12 MONTHS AFTER DETERMINATION OF DETERMINATION OF PERMANENCEPERMANENCE
ONCE VS IS PERMANENT - DNR ONCE VS IS PERMANENT - DNR ORDER IS APPROPRIATE (MAY BE ORDER IS APPROPRIATE (MAY BE MADE EARLIER)MADE EARLIER)
ISSUES AND ISSUES AND CONTROVERSIESCONTROVERSIES
ANALYSIS OF DATA AND LIMITATIONSANALYSIS OF DATA AND LIMITATIONS LIFE EXPECTANCYLIFE EXPECTANCY EMERGENCE FROM VSEMERGENCE FROM VS
MCS - A NEW TERM AND PATIENT MCS - A NEW TERM AND PATIENT CATEGORY - LITTLE DATACATEGORY - LITTLE DATA
GRAY ZONE BETWEEN VS & MCSGRAY ZONE BETWEEN VS & MCS CONFLICT RESOLUTION & CROSS CONFLICT RESOLUTION & CROSS
DISCIPLINARY CONSENSUSDISCIPLINARY CONSENSUS PAIN AND SUFFERING IN VS AND MCSPAIN AND SUFFERING IN VS AND MCS
RECENT RESEARCH RECENT RESEARCH DEVELOPMENTSDEVELOPMENTS
FUNCTIONAL VS – PATIENTS MAY APPEAR FUNCTIONAL VS – PATIENTS MAY APPEAR VS BUT ACTUALLY BE MCSVS BUT ACTUALLY BE MCS
LIKELY ARE WIDE VARIATIONS IN BRAIN LIKELY ARE WIDE VARIATIONS IN BRAIN METABOLISM IN VS WITH SOME CEREBRAL METABOLISM IN VS WITH SOME CEREBRAL REGIONS RETAINING PARTIAL FUNCTIONREGIONS RETAINING PARTIAL FUNCTION
NOCICEPTIVE STIMULI MAY PRODUCE NOCICEPTIVE STIMULI MAY PRODUCE INCREASED BRAIN ACTIVITY IN PRIMARY INCREASED BRAIN ACTIVITY IN PRIMARY SOMATOSENSORY CORTEX IN VS – SOMATOSENSORY CORTEX IN VS – DISASSOCIATED WITH HIGHER ORDER DISASSOCIATED WITH HIGHER ORDER ASSOCIATIVE CORTEX ACTIVATIONASSOCIATIVE CORTEX ACTIVATION
RECENT RESEARCH RECENT RESEARCH DEVELOPMENTSDEVELOPMENTS
IN A SUBPOPULATION OF VS PATIENTS, THERE IS IN A SUBPOPULATION OF VS PATIENTS, THERE IS PRESERVATION OF THALAMOCORTICAL FEEDBACK PRESERVATION OF THALAMOCORTICAL FEEDBACK CONNECTIONS THAT ALLOW FOR CORTICAL CONNECTIONS THAT ALLOW FOR CORTICAL INFORMATION PROCESSING AND MAY EVEN INFORMATION PROCESSING AND MAY EVEN INVOLVE SEMANTIC LEVELS OF PROCESSINGINVOLVE SEMANTIC LEVELS OF PROCESSING
RECOVERY OF CONSCIOUSNESS APPEARS TO BE RECOVERY OF CONSCIOUSNESS APPEARS TO BE ASSOCIATED WITH RESTORATION OF ASSOCIATED WITH RESTORATION OF CORTICOTHALAMOCORTICAL INTERACTIONCORTICOTHALAMOCORTICAL INTERACTION
SOME MCS PATIENTS MAY RETAIN WIDELY SOME MCS PATIENTS MAY RETAIN WIDELY DISTRIBUTED CORTICAL SYSTEMS WITH DISTRIBUTED CORTICAL SYSTEMS WITH POTENTIAL FOR COGNITIVE AND SENSORY POTENTIAL FOR COGNITIVE AND SENSORY FUNCTION DESPITE THEIR INABILITY TO FOLLOW FUNCTION DESPITE THEIR INABILITY TO FOLLOW SIMPLE COMMANDS OR RELIABLY COMMUNICATESIMPLE COMMANDS OR RELIABLY COMMUNICATE
FUTURE DIRECTIONS FOR FUTURE DIRECTIONS FOR RESEARCHRESEARCH
INCIDENCE AND PREVALENCE OF VS AND MCS INCIDENCE AND PREVALENCE OF VS AND MCS IN TBIIN TBI
NATURAL HISTORY, RECOVERY COURSE AND NATURAL HISTORY, RECOVERY COURSE AND LONG TERM OUTCOMELONG TERM OUTCOME
LEVELS OF CERTAINTY ASSOCIATED WITH LEVELS OF CERTAINTY ASSOCIATED WITH PREDICTORS OF RECOVERYPREDICTORS OF RECOVERY
UTILITY OF ASSESSMENT METHODSUTILITY OF ASSESSMENT METHODS TREATMENT EFFICACYTREATMENT EFFICACY IMPACT OF OPTION DISSEMINATIONIMPACT OF OPTION DISSEMINATION EXAMINATION OF FAMILY BELIEFS AND EXAMINATION OF FAMILY BELIEFS AND
RELATION TO OUTCOME/UTILIZATIONRELATION TO OUTCOME/UTILIZATION
WATCH FOR:WATCH FOR: ““BRAIN INJURY MEDICINE: PRINCIPLES BRAIN INJURY MEDICINE: PRINCIPLES
AND PRACTICE” AND PRACTICE” EDITED BY N. ZASLER, D. KATZ AND R. EDITED BY N. ZASLER, D. KATZ AND R.
ZAFONTEZAFONTE CORE TEXTBOOK ON TBI ASSESSMENT AND CORE TEXTBOOK ON TBI ASSESSMENT AND
MANAGEMENTMANAGEMENT OVER 60 CHAPTERS WRITTEN BY OVER 60 CHAPTERS WRITTEN BY
INTERNATIONAL LEADERS IN THE FIELDINTERNATIONAL LEADERS IN THE FIELD PUBLISHED BY DEMOS PUBLICATIONS - NY, NYPUBLISHED BY DEMOS PUBLICATIONS - NY, NY EXPECTED DATE OF PUBLICATION IS EARLY EXPECTED DATE OF PUBLICATION IS EARLY
20062006
CCCVCCCV
QUESTIONS QUESTIONS AND AND
ANSWERSANSWERS