Prolonged Disorders of

Consciousness:

Emergence from minimally

conscious states Katrina Clarkson, Principal Speech and Language Therapist

kclarkson@nhs.net Beverley Fielding, Clinical specialist Occupational Therapist b.fielding@nhs.net September 2016 Regional Hyper-acute Rehabilitation Unit Northwick Park Hospital

Reality check

Likelihood of emergence diminishes over

time

Cause of brain injury is a strong indicator

of outcome

– Non traumatic brain injury (anoxic/diffuse)

– Traumatic brain injury

RCP Prolonged Disorder of Consciousness National Clinical Guidelines 2013

Emergence signal

CRS-R: Items denoting emergence from

MCS are highlighted with †

– Motor Function scale (Functional object use)

– Communication scale: Functionally accurate

to situational questions

WHIM: Items from approximately 29

onwards are starting to show possibility of

emergence from PDOC.

Emergence from MCS

Reliable and consistent responses.

Using set tasks

– 2 consecutive evaluations

In one or both

– Functional interactive communication

– Functional use of objects

(RCP National Clinical Guidelines - Prolonged Disorder of Consciousness

2013 and Giacino et al 2002)

Interfering factors

Sensory impairments

– language / vision / hearing

Motor impairments

– Weakness / contractures / ataxia

Cognitive deficits/confusion

Second language English

(RCP Prolonged Disorder of Consciousness National Clinical Guidelines 2013; Annex 1a)

Extended set of emergence

parameters Demonstrate a consistent response in one

of the following:

– Functional use of objects

– Consistent discriminatory choice-making

– Functional communication (Biographical

Questions)

– Functional communication (Situational

questions)

Case study: Mrs F

Personal Information

– 66yr old female

Social Information

– Married

– Working as an

Occupational Psychologist

– Two grown up children

CASE STUDY: Mrs F

Background:

– RTA: pedestrian v’s van March 2015

– Severe traumatic brain injury

Extensive bilateral SAH

Large haemorrhagic contusion in right temporal lobe

Bifrontal subdural hygromas (CSF)

MRI – axonal injury involving thalamus, midbrain

and cerebellum bilaterally.

– Polytrauma

Fracture of 7th cervical vertebra

Multiple rib fractures

CASE STUDY: Mrs F

Impairments on admission (May 2015):

– PDOC

– Severe tetraparesis

But: spontaneous movement in arms and legs

– Tracheostomy in situ

– Reliant on PEG feeding

– Fully dependent for all care

Management Mrs F

Assessed regularly with WHIM and CRS-R

– Upward trajectory

– Localising and differentiating responses

– Increased verbal responses

Formally emerged August (3 months later)

– Using functional objects – hairbrush, cup

– Two consecutive occasions, within 72 hrs

WHIM Data

CRS-R Data

Video Example:

Purposeful behaviours

DISCHARGE VIDEO Mrs F

2 months after emergence

Case study: Mr D

Personal Information

– 35 yr old male

Social Information

– Married with 2 children,

10yr and 9yr

– Working as a Mechanic

CASE STUDY: Mr D

Background:

– Collapse at home

– CVA: Left MCA infarct (February 2015)

– Haemorrhagic transformation

– Decompressive craniectomy

CASE STUDY: Mr D

Impairments on admission (March 2015):

– PDOC – no visual fixation or tracking

– Right hemiplegia

– Severe spasticity on right

– Tracheostomy in situ

– Reliant on NG feeding

– Fully dependent for all care

Management: Mr D

Assessed regularly with WHIM

– Clear upward trajectory

– Localising and differentiating responses

Formally emerged April (1 month later)

– Using functional objects –cup, glasses, wiping

mouth with a tissue

– Two consecutive occasions

WHIM Data

Discharge Video Mr D

5 months after emergence

Summary

Reliable and consistent responses.

Using set tasks

– 2 consecutive evaluations

In one of:

– Functional use of objects

– Consistent discriminatory choice-making

– Functional communication

Biographical questions

Situational questions (RCP National Clinical Guidelines - Prolonged Disorder of Consciousness

2013)

Thank you for listening

Any Questions?

Acknowledgements

Thank you to the patients and their families

for permission to present data

References

Turner-Stokes, Bassett, Rose, Ashford and Thu (2015)

Serial measurement of Wessex Head Injury Matrix in the

diagnosis of patients in vegetative and minimally

conscious states: a cohort analysis. BMJ Open 5.

Shiel, Wilson, McLellan, Horn and Watson (2000). The

Wessex Head Injury Matrix (WHIM) main scale: a

preliminary report on a scale to assess and monitor

patient recovery after severe head injury. Clin Rehabil;

14:408–16.

Giacino, Ashwal, Childs, Cranford, Jennett, Katz, Kelly,

Rosenberg, Whyte, Zafonte, and Zasler (2002) The

Minimally Conscious State: Definitions and diagnostic

criteria. Neurology, 58: 3 349-353.

References

Giacino, Kalmar, Whyte. (2004) The JFK Coma

Recovery Scale-Revised: measurement characteristics

and diagnostic utility. Arch Phys Med Rehabil 85: 2020–

9.