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

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QUESTIONS QUESTIONS AND AND

ANSWERSANSWERS