Predictors of Outcome in Prolonged Posttraumatic Disorders of Consciousness and Assessment of Medication Effects: A Multicenter Study
What factors, if any, can predict recovery from prolonged unconsciousness, and is there preliminary evidence that specific medications contribute to this recovery?
Past Studies reported difficulty in finding reliable guidelines for predicting outcomes for people with severe traumatic brain injury (TBI) who were admitted to an acute rehabilitation hospital in a vegetative state (VS) or minimally conscious state (MCS). The small size of most study samples has made it difficult to predict which patients will have a greater degree of recovery and which medication or rehabilitation therapy will provide the greatest gains in recovery. There is a lack of definitive data regarding the effects of treatment on recovery from prolonged impairments of consciousness and a lack of data on the possible therapeutic benefit and adverse effects of medication use. Some studies have suggested that lesion location might be a better predictor of outcome for individuals in vegetative or minimally conscious states.
This Study included 124 patients selected from the “Consciousness Consortium,” a group of six rehabilitation facilities located in the United States and one facility in Germany. The patients were admitted with severe TBI and were in a vegetative state (VS) or minimally conscious state (MCS) at the time of admission. The intent of this observational study was to gather information from the seven rehabilitation facilities to identify outcome predictors for individuals with prolonged posttraumatic disorders.
Data from these facilities were sent to the Moss Rehabilitation Research Institute database for analysis. The following variables were examined: demographic information, injury and acute care history, neuroimaging data, the Disability Rating Scores (DRS) collected at enrollment, and medications given by the treating physicians. The researchers found that the time between injury and admission, the DRS score at admission, and the rate of improvement in DRS scores over the first 2 weeks after admission were the best predictors of recovery. These 3 variables were strong predictors of a later DRS score and of the time until commands were first followed. Certain psychoactive medications appeared to predict later DRS scores, but not time until commands were first followed, which may reflect their impact on improvements in consciousness (among those who have regained some consciousness) rather than return of consciousness.
The Glasgow Coma Scale (GCS), brain lesions, and the presence of early complications all showed a lack of predictive power in outcomes of persons in vegetative or minimally conscious states. The researchers note that this may have resulted from using medical record data that sometimes lacked quality.
The information from this study will be important to consider in future clinical programs and research designs. Researchers also recommend further study of the effects of medication.
Who May Be Affected By These Findings
People with brain injury and their families, researchers, caregivers, health professionals and community providers.
The methods used for this study, that is, use of medical records rather than direct observation, limit what conclusions can be drawn about treatment effects, use of predictive models across the board, and availability and quality of data from acute care referral sources. This study suggested that available clinical data from charts was not highly predictive of outcomes for individuals with TBI. The authors recommended using a standard data collection model that might yield more useful information. Randomized controlled trials will be required to definitively establish the impact of psychoactive drugs.
DRS score at the time of rehabilitation admission, time between injury and admission, and rate of improvement in the first 2 weeks after admission, were the only significant outcome predictors. Acute care and neuroimaging variables were not predictive, though this may have been partly because of the variable quality of data on these factors available in routine clinical charts. Psychoactive medications were inconsistently related to outcome in this observational study, emphasizing the need for controlled clinical trials to definitively address this issue.
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Whyte, J., Katz, D., Long, D., DiPasquale, M C., Polansky, M., Kalmar, K., Giacino, J., Childs, N., Mercer, W., Novak, P., Maurer, P,. Eifert, B. (2005). Predictors of Outcome in Prolonged Posttraumatic Disorders of Consciousness and Assessment of Medication Effects: A Multicenter Study. Archives of Physical Medicine Rehabilitation,86, 453-462