Disorders of Consciousness Management in Outpatient Setting · • A long-term survival study of...
Transcript of Disorders of Consciousness Management in Outpatient Setting · • A long-term survival study of...
Disorders of Consciousness Management in Outpatient Setting
Disclosure Statement
Kirstine Carter, Ph.D.
Alyssa Kelly, MA, CCC-SLP
Kimberly Larriviere, OTR/L
Margaret McKinney, PT, DPT
• Financial – No financial disclosures.
• Non-Financial – Employees of TIRR Memorial Hermann.
Receive no compensation for speaking/presenting on the
topic of DoC. Have no relevant relationship with products
or services describe, reviewed, or compared in this
presentation.
Objectives
• Provide an overview of Disorders of
Consciousness (DoC)
• Understand the role of outpatient
transdisciplinary team as critical part of
continuum of care for patients with DoC
• Understand program development for
outpatient setting for patients with
Disorders of Consciousness
Arousal vs. Awareness
Kothari, S., Gilbert-Baffoe, E., & O’Brien, K.A. (2018). Disorders of Consciousness. In Eapen & Cifu (Eds.),
Rehabilitation After Traumatic Brain Injury (pp. pages of chapter). Location: Publisher.
AROUSAL AWARENESS
COMA - -
VEGETATIVE STATE
(VS)
+/++ -
MINIMALLY
CONSCIOUS STATE
(MCS)
+/++ +
EMERGED FROM
MCS
++ ++
Arousal vs. Awareness
• Arousal – level of consciousness
• Awareness – content of consciousness
• MUST have arousal before someone can
demonstrate awareness
Laureys, S., Boly, M., Moonen, G., and Maquet, P. (2009). Coma. Encyclopedia of neuroscience, 2, 1133-1143.
Definition of DoC
Courtesy of Dr. Kothari
DEATH LIFE
UNCONSCIOUSNESS
COMA VEGETATIVE STATE
CONSCIOUSNESS
MINIMALLY CONSCIOUS STATE
CONSCIOUS
Behaviors in Vegetative State and MCS
Kothari, S., Gilbert-Baffoe, E., & O’Brien, K.A. (2018). Disorders of Consciousness. In Eapen & Cifu (Eds.), Rehabilitation After Traumatic Brain Injury
(pp. pages of chapter). Location: Publisher.
Big Picture: Quick Glance
• Eyes closed, no sleep wake: comatose
• Eyes open, sleep wake: vegetative or
unresponsive wakefulness (UWS)
• Eyes open, inconsistent awareness of
environment and/or self: minimally conscious
(MCS)
• Eyes open, aware of environment and/or self:
emerged
Assessment of DoC
• 40% of pts diagnosed with Vegetative State
were discovered to be conscious with
standardized behavioral measures (Schnakers, et. Al, 2009)
• A long-term survival study of adult trauma
patients found that patient’s discharged to a
skilled nursing facility were 34% more likely to
die 3 years post-TBI than those discharged to
home or to rehabilitation facilities (Davidson, et. al, 2011)
Assessment of DoC
• Behavioral measures are gold standard
– Coma Recovery Scale-Revised (CRS-R )
– Individualized Quantitative Behavioral
Assessment (IQBA)
• Require training and frequent repetition
• Can help identify how to structure your treatment
Day, K.B., DiNapoli, M.V., Whyte, J. (2017). Detecting early recovery of consciousness: A comparison of methods. Neuropsychology Rehabilitation, Apr 7 (1-
9). doi: 10.1080/09602011.2017.1309322.
Factors Masking Consciousness
• Hypoarousal
• Medical (medications, hydrocephalus,
infection)
• Spasticity and contracture
• Environment
• Apraxia
• Attention span
• Impaired sleep-wake cycles
• Neuromuscular impairments including
strength deficits, visual deficits, auditory
deficits, etc.
*These are potential factors that
should be considered during
evaluation and treatment*
Giacino, J.T., Schnakers, C., Rodriguez-Moreno, D., Kalmar, K., Schiff, N., Hirsch, J. (2009). Behavioral assessment in patients with
disorders of consciousness: Gold standard or fool’s gold?. Progress in Brain Research, 177, 63-72.
https://doi.org/10.1016/S0079-6123(09)17704-X
Transition to Outpatient
Outpatient Setting-Evaluation
DoC specific medical background
• Date of injury, type of injury (traumatic vs non-
traumatic, anoxic?), time since injury
• Inpatient stay? Identify if CRS-R testing was
done and use results to guide evaluation
• Communication system?
• Family/caregiver report of current behaviors,
videos if possible
Ontario Neurotrauma Foundation. (2016, October). Clinical practice guideline for the rehabilitation of adults with moderate to severe tbi: Section I: Assessment
and rehabilitation of brain injury Sequelae [Data file]. Retrieved from
https://braininjuryguidelines.org/modtosevere/fileadmin/Guidelines_components/Rec/Section_2_REC_complete_ENG_final.pdf
Outpatient Setting-Evaluation
DoC specific medical background
• Medication review
- Depressants
- Stimulants? Trialed stimulants? Timing of
stimulants
• Arousal throughout the day
• Sleep-wake cycles
C., Rosella, Placido B.,Savatore Calabro, R., (2013). Pharmacotherapy for disorders of consciousness: Are ‘awakening’ drugs really a possibility?.
Drugs, 73(17), 1849–1862.
Outpatient Setting-Examination
Non-DoC specific• Vitals - Tracheostomy Management, Pulmonary Care, Secretion Management
• Bladder and Bowel management
• Oral and Dental Hygiene
• Spasticity (Modified Ashworth Scale and Tardieu) – Intrathecal Baclofen Pump (ITB)
• Joint Movement and Range of Motion Exercise – Posture and Position
• Mobility Management – Transfers, Bed Mobility, Head Control
• Prevention of Secondary Complications – Skin breakdown, Nutrition, Deep Vein
Thrombosis
• Equipment and Orthotics
• Adaptive Technology and Environmental Management
• Communication – Established System, Responding to Yes/No questions
• Family Support – Counseling and Training
Klingshirn, H., Grill, E., Bender, A, Strobl, R., Mittrach, R., Braitmayer, K., Muller, M., (2015). Quality of evidence of rehabilitation interventions in longterm care
for people with severe disorders of consciousness after brain injury: A systematic review. J Rehabil Med, 47, 577-585.
Outpatient Setting-Examination
• According to Elliott, Coleman, and Shiel (2005, p. 299) “positional
changes may have a significant impact on behaviours in vegetative
and minimally conscious patients.”
• Determine the following in a variety of positions and with different
stimuli:
– Are they aroused?
– Do they move? reflexive, spontaneous, repetitive, to command *
(against gravity or gravity eliminated)
– Do they respond to auditory input?
– Do they respond to visual input?
– Do they vocalize?
Remember to keep in mind what you have learned
about their PMH, area of injury and how this may
impact their success at demonstrating these things
Goal Setting
• Collaborative goal setting between family,
therapists, physician, and neuropsychologist
• Determine what primary goal is for this patient
and this phase of therapy
– Establishing consciousness, communication,
or is it more of caregiver training, HEP, etc.
Giancino, J.T., Douglas, I., Katz, D.I., Schiff, N.D., Whyte, J., Ashman, E.J., Ashwal, S., Barbano, R., Hammond, F.M.,
Laureys, S., Ling, G.S.F., Nakase-Richardson, R., Seel, R.T., Yablon, S., Getchius, T.S.D., Gronseth, G.S., Armstrong,
M.J. (2018) Practice guideline update recommendations summary: Disorders of consciousness. Neurology, 91, 1-11. doi:
10.1212/WNL.0000000000005926
Sample Goals
• Samples:
– Consistency of command following
– Visual tracking
– Head control
– Seated balance
– Standing tolerance
– Swallowing
– HEP
• MUST discuss goals with other disciplines to prevent
goal replication
*Refer to Sample OT Goals for examples
Assessment in Outpatient: IQBA
• Emphasis on behavioral assessment in treatment of DoC
clients (Giacino et. al., 2018)
• IQBAs can be created in the OP setting with Neuropsychology
• IQBA may detect command following quicker than CRS-R
(Day, DiNapoli & Whyte, 2017)
• More practical than CRS-R in this setting
• Reasons to use:
– Used when behavior is ambiguous to see if it can be use
for a communication system
– Used during medication trials for pre- and post-data
• VERY objective, requires consistency with administrators and
instruction language
Assessment in Outpatient: IQBA
• Development of IQBA, as a team decide:
(1.) Session administration variables such as patient positioning,
stimulation to maximize alertness, preliminary range of motion
exercises to facilitate motor responding
(2.) The commands to be given, the number to be administered, the
manner of administration, and the random order within a particular
session
(3.) The operational definition of a response and a format for
recording responses
(4.) Control conditions to minimize the influence of coincidental and
reflexive responding.
(Whyte, DiPasquale & Vaccaro, 1999)
Assessment in Outpatient: IQBA
• Importance of multidisciplinary team
• Involvement of caregivers
• Clinical uses of IQBA in outpatient
– Determine if client is following commands
– Assist in development of communication
system
– Can track progress of recovery and response
to treatment
Integrating Behavioral Measures for Treatment
• It is ideal to use what you have observed
on standardized, behavioral measures in
your interventions.
– For example, if patient A does not respond to
visual stimuli, it may be appropriate to target
interventions using auditory input rather than
visual input.
Decision Tree
Treatment Interventions
Sessions to target:
• Impaired arousal and/or consciousness
- Neurostimulating positions and interventions
• ROM restrictions and or spasticity/hypertonicity
impairing wheelchair or bed positioning
- Serial casting, splinting
- Wheelchair set up or positioning; positioning programs
• Command following
• Home exercise program and family training
Wilson, B.A., Dhamapurkar, S., & Rose, A. (2016). Assessment and treatment of people with a disorder of consciousness: An account of some recent
studies. Psychology & Neuroscience, 9(2), 221–229.
Neurostimulating Interventions
• Using consistent
commands across
disciplines and tracking
responses and arousal in
sessions
• Commands should be
mixed with counter-
commands, silence and
enough time for the pt to
respond
Get creative!
Home Exercise Program (HEP)
• Arousal
• Standing programs
• Range of motion
exercises
• Orthotics wear schedule
• IQBA Family could
implement IQBA if
applicable
Seel, R.T., Douglas, J., Dennison, A.C., Heaner, S., Farris, K., Rogers, C. (2013). Specialized early treatment for persons with disorders of
consciousness: Program components and outcomes. Arch Phys Med Rehabil, 94(10), 1908-23.
Things to Consider
• Use of equipment and technology:
– Switches, e-stim, FES bike, litegait, sEMG
• Communication with MD:
– Medication trials, lumbar puncture, sleep study, ITB
pump
• Barriers and/or facilitators:
– Time of day, caregiver support, resources, endurance
for activity, order of therapy, expectations for therapy
Ontario Neurotrauma Foundation. (2016, October). Clinical practice guideline for the rehabilitation of adults with moderate to severe tbi: Section II :
Assessment and rehabilitation of brain injury Sequelae [Data file]. Retrieved from
https://braininjuryguidelines.org/modtosevere/fileadmin/Guidelines_components/Rec/Section_2_REC_complete_ENG_final.pdf
Discharge
• Giving clear HEP tailored to level of
consciousness
• Expectations of when to return to therapy or
return to MD
– Consciousness change
– Traditional therapy needed (bracing,
equipment, HEP update, etc.)
– Change in status that opens up new goals for
rehabilitationAmerican Speech-Language Hearing Association (n.d.). Documentation in healthcare. Retrieved from
https://www.asha.org/PRPSpecificTopic.aspx?folderid=8589935365§ion=Key_Issues
Outpatient Program Creation
Summer 2017- Present
• Fall 2017:
– Creation of primary inter-disciplinary team
– Meeting with inpatient, outpatient medical and
outpatient staff
• Winter/Spring 2018:
– Training modules for all staff and BI-specific
(4 modules)
– Journal Clubs with inpatient team
Outpatient Program Creation
• Spring/Summer 2018:
– Lunch meetings with primary OP team and
monthly meetings with IP team
– First referral Spring 2018
• Summer/Fall 2018:
– Additional patients admitted to program
– Competency for OP BI Team for DoC
– Monthly/bi-monthly rounding
Potential barriers in OP
• Insurance limitations
• Staff education (specialized group)
• Communication between staff
• Scheduling
• Family and caregiver support and abilities
• Design of HEP and Plan of Care (POC)
• Measuring of Progress, Outcome measures
• Transportation
• Fatigue
Case Study- LE
• OP Community referral for OPMC, PT/OT/SLP evaluations on
2/9/18
• Patient background information:
– GSW in 11/4/15 followed by anoxic injury 11/8/15 from
cardiopulmonary arrest
– Inpatient rehabilitation 4/25/16 for 1 month and had short follow-
up of home health
– Pt with very supportive family and living with mother and father,
2 children who his mother observed interacting with
grunting/clicking noises, not performing movements
spontaneously or to command. HEP including standing in
stander, B UE and B LE stretches
– Family goals- communication system, walk and talk
– Medicaid required authorization
Case Study- LE
• Initial Evaluation:
– PT – total A for all mobility, 10 sec head control when placed in position,
moro reflex
• Initial PT goals: HEP, maintain head control for 30 seconds,
caregiver safety of transfer
– OT – total A for all Activities of Daily Living, flexor synergy positioning of
Bilateral Upper Extremities
• Initial OT goals: HEP, donning positioning devices
– SLP – NPO, groaned in response to non-preferred action, localization of
sound reported but not observed at evaluation
• Initial SLP goals: HEP, demonstrate localized response to auditory
stimulation, vocalize in response to pain/discomfort, follow stimuli
through left and right visual fields, elicit a swallow with thermal
tactile stimulation
• Initial Authorization Visit Count: PT (8), OT (4), SLP (8)
Case Study – LE
• Action Steps
– Contacted physician to schedule sleep study
– Discussed medication trials
– Discussed sitting schedule to be up more
during the day
– Coordinated scheduling of Lumbar Puncture
for possible hydrocephalus
Case Study- LE
• Treatment: started 4/3/18
– Coordination with PT, OT, SLP of observations of arousal, reflexive and
spontaneous movement
– Trialed variety of stimulation
• Auditory- music, family voices
• Visual- pictures of children, familiar objects, mirror
• Tactile- e-stim, different surfaces, oral stimulation
• Vestibular- rocking in tilting in space wheelchair, standing, prone,
seated positions
– Creation of IQBA for pt for tracking in session and as HEP
• Tracking behavior in and out of session
• Pre- and post-medical intervention
– Family training for IQBA and HEP
– Pt discharged due to transportation and to return to OP services when
mother retires and following possible shunt surgery.
Case Study- LE Results
• Family subjective perceived improvement:
improvement in arousal, increased in
vocalizations with family
• Unable to establish a communication system
• Inadequate OT goal writing led to decreased
authorized visits as compared to SLP and PT
• Importance of family training
Areas for Program Growth & Improvement
• Involve Neuropsychology from the
beginning
• Improved rounding and handoffs
• Improved goal writing and documentation
• Referrals from other sources
• Continuum of care, transitioning between
settings
References
1. American Speech-Language Hearing Association (n.d.). Documentation in healthcare. Retrieved from
https://www.asha.org/PRPSpecificTopic.aspx?folderid=8589935365§ion=Key_Issues
2. Betts, K. & Cheng, V. (2018). Disorders of consciousness: A comprehensive treatment approach. [PowerPoint slides]. TIRR Memorial Hermann:
Rehabilitation & Research, Houston, Texas.
3. Davidson, G.H., Hamlat, C.A., Rivara, F.P., Koepsell, T.D., Jurkovich, G.J., Arbabi, S. (2011). Long-term survival of adult trauma patients. JAMA, 305, 1001-
1007.
4. Day, K.B., DiNapoli, M.V., Whyte, J. (2017). Detecting early recovery of consciousness: A comparison of methods. Neuropsychology Rehabilitation, Apr 7 (1-
9). doi: 10.1080/09602011.2017.1309322.
5. Elliott, L., Colemen, M., Shiel, A (2005). Effect of posture on levels of arousal and awareness in vegetative and minimally conscious state patients: a
preliminary investigation. J Neurol Neurosurg Psychiatry, 76, 298-299.
6. Giancino, J.T., Douglas, I., Katz, D.I., Schiff, N.D., Whyte, J., Ashman, E.J., Ashwal, S., Barbano, R., Hammond, F.M., Laureys, S., Ling, G.S.F., Nakase-
Richardson, R., Seel, R.T., Yablon, S., Getchius, T.S.D., Gronseth, G.S., Armstrong, M.J. (2018) Practice guideline update recommendations summary:
Disorders of consciousness. Neurology, 91, 1-11. doi: 10.1212/WNL.0000000000005926
7. Giacino, J.T., Schnakers, C., Rodriguez-Moreno, D., Kalmar, K., Schiff, N., Hirsch, J. (2009). Behavioral assessment in patients with disorders of
consciousness: Gold standard or fool’s gold?. Progress in Brain Research, 177, 63-72. https://doi.org/10.1016/S0079-6123(09)17704-X
8. Klingshirn, H., Grill, E., Bender, A, Strobl, R., Mittrach, R., Braitmayer, K., Muller, M., (2015). Quality of evidence of rehabilitation interventions in longterm
care for people with severe disorders of consciousness after brain injury: A systematic review. J Rehabil Med, 47, 577-585.
9.Kothari, S., Gilbert-Baffoe, E., & O’Brien, K.A. (2018). Disorders of Consciousness. In Eapen & Cifu (Eds.), Rehabilitation After Traumatic Brain Injury (pp.
191-214).
10. Laureys, S., Boly, M., Moonen, G., and Maquet, P. (2009). Coma. Encyclopedia of neuroscience, 2, 1133-1143.
References cont.
11. Ontario Neurotrauma Foundation. (2016, October). Clinical practice guideline for the rehabilitation of adults with moderate to severe tbi: Section I:
Assessment and rehabilitation of brain injury Sequelae [Data file]. Retrieved from
https://braininjuryguidelines.org/modtosevere/fileadmin/Guidelines_components/Rec/Section_2_REC_complete_ENG_final.pdf
12. Ontario Neurotrauma Foundation. (2016, October). Clinical practice guideline for the rehabilitation of adults with moderate to severe tbi: Section II :
Assessment and rehabilitation of brain injury Sequelae [Data file]. Retrieved from
https://braininjuryguidelines.org/modtosevere/fileadmin/Guidelines_components/Rec/Section_2_REC_complete_ENG_final.pdf
13. Riganello, F., Arcuri, F., Pugliese, M.E., Lucca, L.F., Dolce, G., & Sannita, W.G., (2015). Coma recovery scale-r: Variability in the disorder of
consciousness. BMC Neurology, 15:186, 1-7. doi https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4599033/pdf/12883_2015_Article_455.pdf
14. Rosella, C., Placido, B.,Savatore Calabro, R., (2013). Pharmacotherapy for disorders of consciousness: Are ‘awakening’ drugs really a possibility?. Drugs,
73(17), 1849–1862.
15. Schnakers, C., Vanhaudenhuyse, A., Giancino, J., Ventura, M., Boly, M., Majerus, S., Moonen, G., Laureys, S. (2009). Diagnostic accuracy of the
vegetative and minimally conscious state: Clinical consensus versus standardized neurobehavioral assessment. BMC Neurology, 9(35), 1-5.
https://bmcneurol.biomedcentral.com/track/pdf/10.1186/1471-2377-9-35.
16. Seel, R.T., Douglas, J., Dennison, A.C., Heaner, S., Farris, K., Rogers, C. (2013). Specialized early treatment for persons with disorders of consciousness:
Program components and outcomes. Arch Phys Med Rehabil, 94(10,) 1908-23.
17. Whyte, J., & Dipasquale, M. C. (1995). Assessment of vision and visual attention in minimally responsive brain injured patients. Archives of physical
medicine and rehabilitation, 76(9), 804-810.
18. Whyte, J., DiPasquale, M. C., & Vaccaro, M. (1999). Assessment of command-following in minimally conscious brain injured patients. Archives of Physical
Medicine and Rehabilitation, 80(6), 653-660.
19. Wilson, B.A., Dhamapurkar, S., & Rose, A. (2016). Assessment and treatment of people with a disorder of consciousness: An account of some recent
studies. Psychology & Neuroscience, 9(2), 221–229.
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