Ontario Neurotrauma Foundation

Clinical Practice Guideline

For the rehabilitation of Adults with Moderate to Severe TBI

Ontario Neurotrauma Foundation INESSS
SECTION 1: Components of the Optimal TBI Rehabilitation System > B. Management of Disorders of Consciousness

B. Management of Disorders of Consciousness

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One in eight patients with severe closed head injury has been reported to suffer from prolonged coma and vegetative state as a consequence of the head injury. The prognosis is not always poor.  50% of vegetative survivors of severe brain injuries are able to regain consciousness within one year of injury and up to 40% subsequently improve to a higher level of the GCS. Sensory stimulation in particular has been promoted as a means to facilitate recovery and counter the negative impact of sensory deprivation often present in institutional care.  Multi-modal stimulation may improve outcomes but too much stimuli may be more than the injured brain can handle. Close observation of responses to controlled stimuli allows for monitoring of progress.  Carefully and gradually mobilizing these patients helps reduce the potential adverse effects associated with immobilization.

Patients with disorders of consciousness, in particular coma or a minimally conscious state, require ongoing access to interdisciplinary and specialized care. As such, not all centres may be able to provide this level of specialized care, even with adequate resources to monitor and rehabilitate these challenging patients.  There must be frequent reassessment using standardized assessments. The degree of stimulation and mobilization needs to be monitored as the optimal balance of stimulation and rest is not known.

 

Indicators examples

  • Proportion of individuals with a severe disorder of consciousness who are assessed monthly during the first year post injury.

The following are suggestions of tools and resources that can be used to support the implementation of the recommendations in this section. Healthcare professionals must respect the legal and normative regulations of the regulatory bodies, in particular with regards to scopes of practice and restricted/protected activities, as these may differ provincially

Clinical Tools:

Patient and Family Resource:

Other Resource:

Abbasi et al. (2009) conducted a well-designed randomized controlled trial (RCT) to evaluate the effects of sensory stimulation through structured family visits on consciousness as assessed by the Glasgow Coma Scale (GCS). Families received training on coma; how to provide appropriate stimulation and how to remain calm. Patients receiving family visits showed significantly greater GCS scores on each day of the intervention and attained a mean GCS 2 points higher than the control group. Although no long-term outcomes were evaluated and no follow-up was reported, these results suggest that family-provided stimulation may be an effective intervention for stimulating recovery from a coma. In the only other RCT identified on this topic, Johnson et al. (1993) randomly assigned patients to a group that received multimodal sensory stimulation or to a group that received no purposeful sensory stimulation at all. The primary outcome in this study was changes in the GCS post treatment. However, Johnson et al. (1993) did not report any data on this measure and only presented data on biochemical and physiological parameters of questionable clinical importance. The strength of the study findings have been questioned due to the “poor” methodological score (PEDro = 3); conclusions, were not based upon the study’s findings. Overall, the studies identified in this area generally show greater improvements in a variety of measures following multimodal sensory stimulation. Some studies aimed to investigate if the duration of coma could be reduced using sensory stimulation as their only objective. For example, Mitchell et al. (1990) reported that patients subjected to multimodal sensory stimulation experienced significant reductions in the duration of coma compared with controls. Again, duration of coma was their only outcome and in the absence of other measures of clinical importance, such as functional indicators (i.e. Glasgow Outcome Scale or Disability Rating Scale), such results fall short in demonstrating any clinical functional benefit of sensory stimulation. A 2002 Cochrane review showed similar results stating that there was insufficient evidence to refute or support the use of multisensory programs for patients in coma or vegetative state (Lombardi et al., 2002). 

REFERENCES
Abbasi, M., Mohammadi, E., & Sheaykh Rezayi, A. (2009). Effect of a regular family visiting program as an affective, auditory, and tactile stimulation on the consciousness level of comatose patients with a head injury. Jpn J Nurs Sci, 6(1), 21-26.

Johnson, D. A., Roethig-Johnston, K., & Richards, D. (1993). Biochemical and physiological parameters of recovery in acute severe head injury: responses to multisensory stimulation. Brain Inj, 7(6), 491-499.

Lombardi, F., Taricco, M., De Tanti, A., Telaro, E., & Liberati, A. (2002). Sensory stimulation of brain-injured individuals in coma or vegetative state: results of a Cochrane systematic review. Clin Rehabil, 16(5), 464-472.

Mitchell, S., Bradley, V. A., Welch, J. L., & Britton, P. G. (1990). Coma arousal procedure: a therapeutic intervention in the treatment of head injury. Brain Inj, 4(3), 273-279.

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B1. Management of Disorders of Consciousness

P Priority F Fundamental New Level of evidence A B C
B 1.1 P C

All individuals with a disorder of consciousness should be periodically assessed throughout the first year post-injury, by an interdisciplinary team with specialized experience in traumatic brain injury.

(INESSS-ONF, 2015)

Note: The interdisciplinary team may include the following core professionals: intensivist, neurologist, neurosurgeon, physiatrist, clinical nutritionist, respiratory therapist, physiotherapist, occupational therapist, neuropsychologist, social worker and speech-language pathologist, etc., as appropriate.

B 1.2 C

Where individuals remain in a coma or minimally conscious state following traumatic brain injury, a period of treatment/management in a specialized tertiary centre should be considered if local services are unable to meet their needs for specialized nursing or rehabilitation.

(Adapted from ABIKUS 2007, G81, p. 29)

Note: This may require additional resources over current practice. Ideally, these resources would be placed within existing intensive rehabilitation services.

B 1.3 C

Individuals with disorders of consciousness should benefit from an optimal environment and level of stimulation. The following pragmatic advice is offered:

  • Healthcare professionals and families should be mindful of hypersensitivity and fatigue, and should avoid overstimulation.

  • Stimulation should focus on pleasant sensations such as favourite music, familiar pets, gentle massage, etc., offered one at a time.

  • Family/friends should be asked to control their visits to avoid sensory overstimulation—with only 1–2 visitors at a time, visiting for short periods.

(Adapted from RCP 2013, Section 2; 2.7, p. 34)

Note: Despite the lack of formal research evidence to support coma stimulation programs, controlled stimulation provides the best opportunity to observe responses.

B 1.4 C

Individuals with traumatic brain injury who present a disorder of consciousness should have a graded program to increase tolerance to sitting and standing, to maintain orthostatic tolerance, to provide some stimulus for arousal, and possibly to help maintain postural reflexes, bowel and bladder function, muscle bulk, and bone health.

(INESSS-ONF, 2015) 

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