Yes, as Brian said, I'm Dr. Brooke Murtaugh. I'm an occupational therapist by training, and I'm gonna be leading the course off tonight, but then turn it over to our other experts. Tonight, we are gonna be covering disorders of consciousness. It's such a huge topic, and it's a hot topic right now in brain injury medicine. And the focus tonight and next week, this is a two-part course, is to really take a look at the evidence-based guidelines and how to implement those guidelines and facilitate evidence-based practice every day with our patients, especially those that we serve with disorders of consciousness. We don't have any disclosures, myself, Dr. Rosenbaum, and O'Brien, who you will meet here in a moment, and then Dr. D. Tomaso has disclosures as he's the speaker for the Bureau of Exobionics and Kindred Healthcare. Our objectives, we have several. Again, over the next two nights, we're gonna try and cover quite a bit of information, but we also wanted to provide an avenue and a format where we could discuss with you as the attendees through case studies and really work on applying these guidelines, as well as field questions and problem-solve various cases, or as you are introduced to the information, questions that come up through the content. Dr. D. Tomaso, I'll let you introduce yourself. Sure, I'm Craig D. Tomaso. I am the Medical Director of U.S. Physiatry and a Director of Early Career Physician Development for U.S. Physiatry. We're working through three different disorders of consciousness programs in my career, so I'll try and give you some insights that I have. And again, I'm Dr. Brooke Murtaugh. I am the Brain Injury Program Manager for Madonna Rehabilitation Hospitals in Lincoln and Omaha, Nebraska. I have been working with severe brain injury for 15 years, and especially disorders of consciousness. Dr. Rosenbaum? Hi, I'm Dr. Rosenbaum. I'm a neuropsychologist, and I work in Queens, New York at a subacute facility, Park Terrace Care Center. We are part of Mount Sinai's model system, and the program basically allows us the luxury of carrying patients with disorders of consciousness for a minimum of three months to a maximum of a year, and the intensity of our rehab is comparable to acute inpatient rehab. So we have a specialty disorders of consciousness recovery track that has been there since I started 20 years ago, and so it has been a passion of mine, and that pretty much sums me up. And Dr. O'Brien? Hi, everyone. Thank you for being here. My name is Katherine O'Brien. I'm also a clinical neuropsychologist by training, and I am at Tier Memorial Hermann in Houston, Texas. I'm the Brain Injury Program Manager and the Clinical Director of our Disorders of Consciousness Program, and I'm happy to be here. So just to kind of give a 30,000-foot view of what the next two nights, tonight and next Tuesday, not tomorrow, will cover and what you're in for for the CEU and CME credits. Again, we're gonna go over the disorders of consciousness guideline recommendation, practice guidelines, guideline recommendation, practice guidelines. We're gonna do an overview of that evidence, etiology and clinical pearls of disorders of consciousness, behavioral assessment, and medical evaluation. When there is some challenge and ambiguity to diagnosis using quantifiable assessment to try and decrease some of that ambiguity as these patients can be challenging in several factors that could potentially be masking consciousness. And then we're gonna work through these guidelines and application through case studies. We're gonna try and leave a good chunk at the end of each night to be able to do that. And then night two, we'll cover more in-depth medical management and confounds to consciousness, interdisciplinary approach. As you can see, this is an interdisciplinary panel and faculty tonight, and how that plays such a key role in quality care with those patients. And then transition is that can be challenging. Where do these patients go when they no longer need acute care or medically stable or they're in post-acute care and for a multitude of reasons are no longer appropriate and need to go to an even lesser level of care. And again, we'll work through those concepts through various cases over the two nights. So again, as Brian said, make sure you ask questions. That's what we're here for. It's also a learning process for us to see what questions do other clinicians have across the country that work with these patients at various levels of care. We're gonna attempt to engage you in some interaction through polling questions throughout the case studies. And again, really have that live interaction and discussion. Okay, so we'll get started. So I wanted to do a broad, relatively general overview because what Dr. D. Tommaso and Dr. Rosenbaum are going to share here in a little bit are really gonna start getting into the meat and potatoes of the guidelines and application implementation to disorders of consciousness patients. So again, our objectives just for this section is, I feel it's important to cover a little bit of history of where we've come from with the science surrounding severe brain injury and disorders of consciousness. Really give a background of how did these guidelines that were published by E.G. Acino and his group in 2018, how did we get there? And what was the process to hopefully demonstrate the science behind the guideline recommendations? And I'm also gonna touch on the newer minimal competency recommendations as well and how they're different, but also support the overall practice guidelines that we'll discuss over the next two nights. I as a speaker for this introduction section do not have any disclosures as said previously. So again, quick history because we're not here for history class. So where did we start? Severe brain injury and the phenomenon of brain injury, especially those most severe injuries where they're going to present as coma, unresponsive, low arousal, low awareness. How was that first identified? In the 1960s and again, anybody through medical school, especially neurology background, Plum and Posner's diagnosis of stupor and coma and being able to define or their definition and identification of a coma vigil was in the French literature, but then expanded upon by Plum and Posner in the 60s. And then again, in the 80s. Another seminal piece was by Jeanette and Plum in the Lancet in 1972, more specifically identifying the behaviors and the clinical presentation of individuals in a vegetative state and how that may look a little bit different from said coma vigil and develop the Glasgow Coma Scale that we probably are all familiar with and use or are exposed to daily in our practice. And that was in 1974. So the 70s and 80s, you can really start to see a genesis of being able to look more closely and identify and put a name to these disorders that physicians were seeing after significant head trauma. Then it was several decades before the next seminal piece by Dr. Giacino in the Aspen Working Group back in 2002. So gosh, almost 20 years ago already to define the minimally conscious state. And again, as clinicians at the bedside going, okay, we have the definition of vegetative state and then consciousness, but there's definitely this in between that patients look very different, but yet aren't truly conscious as how we would define it. And so that was published in Neurology in 2002, that operational definition of minimally conscious state, which is considered part of that disorders of consciousness spectrum that we're going to discuss. And then in 2004, you know, how do we identify between coma, vegetative, minimally conscious state? So we have these concepts, this terminology, how do we start to place patients or label them, if you want to say, into these categories that might help us with prognosis, family counseling, what are the next steps? All the things that we're going to talk about, how do we start to conceptualize that in a meaningful way? Because it can be very challenging. And so in 2004, the coma recovery scale was developed by Dr. Giacino and Kathy Kalmar and Dr. John White in 2004. And this assessment, not necessarily used a lot in acute care, but definitely in post-acute and disorders of consciousness programs. It's been heavily researched as well as critically looked at for validity and reliability. And in 2010, by a study by Seal and his colleagues in comparing the CRSR to other coma assessments, really identified the CRSR as having the highest validity and reliability compared to the other assessments that are available for clinicians to use. And we'll go more into the use of the CRSR and what the objective scores mean when creating that clinical picture of this patient as far as diagnosis, prognosis, and trajectory of recovery. And then I think it's interesting to look at the challenges that we face, past and present. And as I look at these, especially in my 15 years of practice and what I knew then and what I know now, there's a lot more information. We know a lot more, but yet we still are facing some of the same challenges that we faced years ago. So past challenges was just increased survival. We know our trauma systems have become so, they're so good at saving lives, especially those severe brain injuries that maybe didn't have a chance at survival previously are now surviving. So are we seeing an increased incidence of those disorders of consciousness patients because they are surviving? Other past challenges is a consensus in the medical community of the definition of coma, vegetative state, minimally conscious state. You know, what is the clinical definition? Can we come to a consensus on that? And I'll speak to that here in a minute again when it comes to present challenges. Lack of general knowledge of disorders of consciousness. Again, if you don't see this every day and aren't able to get access to the literature that's published and the research that's coming out, it's hard to know what to do. I know personally as an OT and then looking at my other rehabilitation colleagues and having these discussions, we're not coming out of our training with this information. This is not a topic that's covered. And if it is not in depth and with any type of training where we can come out, go to the bedside of these patients and be ready to treat and know what to do. Most of the time I'm fielding questions from clinicians, even with several years of experience of what do I do with a patient who isn't doing anything, is not responding, cannot follow commands. So there's just a lack of general knowledge in all domains of care. Diagnostic inaccuracies and errors. I know Dr. Rosenbaum will talk about the incidence of some of these inaccuracies and misdiagnoses with these patients. Limited knowledge of recovery trajectories. You know, what does a patient with severe brain injury who may be in a prolonged state with unresponsive wakefulness or vegetative state or minimally conscious, what do they look like at a year? What do they look like at two years, five years? And we've just had limited knowledge in the past about recovery trajectories and if they have any return of quality of life as we would define it. Talked a little bit about clinical confidence and lack thereof. And then an absence of practice guidelines, which has been remedied. So now fast forward to today, tonight, September 14th, where are we at with the science? You know, a two-sided coin or a double-edged sword is we now have increased functional and advanced neuroimaging such as PET scans, functional MRIs that can look at the brain a little bit more minutely and with more detail. But what is that really telling us? And so that's a question that's happening currently. And a lack of strong methodological large studies in DOC, brain injury research overall, quantitative brain injury research is difficult because it's such a heterogeneous population and so many extraneous variables to control. It can be challenging to get those high level, you know, double-blinded randomized controlled trials where you can, you know, compare apples to apples and be able to get valid and reliable results. Dissemination advances of DOC, hopefully we're doing that now with some of these events and you're seeing more and more conferences as well as conference symposia that do focus on DOC. The implementation of the guidelines, it's a big focus for many of us in DOC world now that the guidelines have been out, you know, really right at three years, are they being implemented? Do people know about them? Do we still need to work on just knowledge translation and dissemination as we work towards implementation? I think we've all heard the statistic that it takes 10 to 15 years for research to be implemented in everyday practice. And we don't want there to be that huge time gap between when these guidelines were published and when we're implementing them at the bedside to benefit our patients with severe brain injury. And then poor access to specialty post-acute rehab. We're gonna talk about those outcomes. Historically, we have thought as a medical community that these patients don't do well and that they don't have any hope that they're gonna be a quote unquote vegetable for the rest of their lives. If we're not withdrawing care in those early days, find the best long-term care facility you can because that's what the end is going to be. And we're finding again through the literature and the evidence that that's just not true. And we'll go through those guideline recommendations and how it relates to post-acute care to be able to hopefully facilitate increased access to quality care throughout the continuum of recovery. Okay, so touching on guidelines and recommendations as we go through. So the genesis of the guidelines. We're gonna talk about this for two nights, six hours total. What is it? If you're not familiar with the guidelines, how did it come to be? Why is there so much emphasis on these guidelines? And I wanna cover that just briefly. So it was a team effort between three major collaborators being the American Academy of Neurology, NIDILRR, the National Institute for Independent Living, Disability and Rehab Research, and then the American Congress of Rehabilitation Medicine. And so those three entities work together to be able to put the manpower and the resources behind this project to support the literature or the research of the literature, promoting and implementing a meta-analysis to come up with these recommendations. So the objectives of the guidelines was to update the American Academy of Neurology's 1995 practice guidelines for vegetative states and to include the 2002 case definition of minimally conscious state. It was also an objective to provide evidence-based recommendations for clinical care. I think those who develop the guidelines knew from their clinical practices, we probably all do, is that everybody kind of does their own thing. What they've learned through their experiences, what they've been taught by their mentors, there's no guideline on what do we do with these patients as there is with so many other illness or injuries of patients that we serve. And the goal was to focus on that prolonged disorders of consciousness. I want you to keep that in mind as we go through the content is prolonged DOC, which is considered minimally conscious or vegetative state or I should have flipped those two, 28 days or longer post-injury. And the reason they make that differentiation of pre-28 days versus post-28 days is how it relates to trajectory of recovery and prognosis, which we'll discuss. So this was a seven-year project. So it took quite a bit of time and manpower to do the literature review. These were all experts in DOC research and practice that were participating in this project. They utilize the American Academy of Neurology practice guidelines process manual. So the AAN has a mandated process that one must go through in order to develop guidelines that should be applied in neurology cases. So they use that process. And then they also implemented the grade process. So in looking at the literature of, they wanted to base the recommendations on the highest level of research that they could come to consensus on through the Delphi voting process that supports the research that would support the recommendation. So they really looked at that literature through a very critical lens and through that grade process of, is this a level one recommendation? Is this a level two recommendation depending on the research that supported that recommendation? So it was a very scientific process. And so then the end product is again, we're applying these guidelines to individuals who are experiencing prolonged disorders of consciousness. And they came up with 18 evidence-based recommendations in the domains of assessment diagnosis, prognosis, prognostic counseling, care and treatment for adults and care and treatment for pediatrics. And then a second piece of literature was published about two years ago. We are right at the two-year mark, I think. It was June of 2020. In the Archives of Physical Medicine and Rehabilitation, we'll be alluding to these minimal competency recommendations as we go through this course. And so what the minimal competency recommendations were was a adjunct and supportive piece to the guidelines, but really focused on the programmatic piece or those organizations that are serving the DOC population and what at a minimum should you be doing to ensure best practice? What are the things that you need to have in your battery of services, teams, care models to be providing the best care? And these are the recommendations that kind of give us a roadmap of what we need to be doing at a minimum to be serving these patients, to ensure and give us some goals of how to provide quality care for these patients. Sorry, I'll back up just a slide here. So the minimal competency recommendations were supported by ACRM again and the Brain Injuries Interdisciplinary Special Interest Group, specifically their Disorders of Consciousness Task Force, as well as the TBI Model System's Disorders of Consciousness Special Interest Group. And so again, was published in the Archives of Physical Medicine and Rehabilitation. The nice thing about this piece of literature is that it does give you an audit checklist. So for myself, who has a DOC program within our organization under our larger brain injury program, I can take this audit checklist and look at it and go, okay, are we doing this? Are we doing this with our patients in these domains? And if not, where are we not in conformance so that we can be able to better improve our program? And so within this document, there's 21 evidence-based and evidenced informed care recommendations. So it didn't have to go through nearly the stringent process as the guidelines, the DOC practice guidelines, but they still did look at the evidence as well as what was their clinical experience or evidenced informed practice so that they could develop these recommendations. So a few more recommendations than the guidelines, and this is for diagnostic and prognostic assessment treatment. So you can see the difference that treatment has quite a few recommendations as it relates to interventions with the DOC population. It also addresses that transition and long-term care needs and management of ethics. So a few different domains than what you'll see in the DOC guidelines, but just as important, because as we know for those of us who work with this population, these are always big questions and big concepts that we have to manage and approach with knowledge as far as transition to care management of ethics and treatment. And then again, the benefits of a specialty DOC program as these minimal competency recommendations not allude to, but the goal is to help facilitate is this specialized treatment and intervention. We wanna increase the accuracy of diagnosis, really support those families and facilitate medical management for these complex care needs that these patients have. So then the overall goal again, for this spotlight event over the next two weeks is we wanna disseminate that evidence-based practice through the recommendations of the practice guidelines and the minimal competency recommendations. And how does this work in the real world? I think all of us who read research or even participate in research and publish research know that sometimes it's difficult to apply it in the real world. And so how can we do that to the best of our ability with these valuable guideline and practice recommendations? And how as a physician can you provide leadership to facilitate that quality care for these patients and their families that are experiencing disorders of consciousness? And we hope to address the guidelines and touch on the minimal competency recommendations at all levels of care. You're attending, we don't necessarily know you. We know physiatry can come into play and get to the bedside of that patient at any level of care whether it's acute care, acute rehab, LTAC, long-term care. So regardless of where you may see that patient in their continuum of care and their recovery, how can you take a look at that patient and look at the evidence and apply the evidence to these patients to provide quality care? And I am going to turn it over to Dr. Rosenbaum. Thank you. Okay, great. Sorry about that. Not the most technologically savvy so of course the worst happens. Anyhow, I'm gonna be talking in this section about the guidelines for diagnostic assessment of disorders of consciousness. And this is a topic that is really important because an accurate diagnosis early on really sets the stage for the whole rest of their recovery. If their initial assessment is not promising, they're most likely not going to be referred for any kind of rehabilitative services. And as Brooke said before, the issue of patients still getting sent to long-term care straight from the hospital is still a persisting challenge even though we have new information about their rehab potential. So first, I have no disclosures to share. These are the learning objectives specifically to this section. We'll talk in general. I'll just give a very brief overview of the different disorders of consciousness and just talk about some comparative features and then dive into the assessment with respect to stopping at different points along the way to discuss the specific guidelines that are associated with each stage of assessment. So first, when we think of disorders of consciousness, I think at least as far as families are concerned, they tend to think of coma as synonymous with disorders of consciousness. Many people don't realize that it's actually a continuum of care. It's really a continuum of a number of disorders. It's not just coma, although commonly families think of coma and consciousness and that's essentially the two extremes that they understand. There's actually a number of conditions that are a part of the equation along the recovery of consciousness after coma. So the things I wanna point out here are number one, the fact that you see the arrows between each state indicating that these are not fixed conditions, that people can jump states. You can go back and forth between states within the course of a day or hours. And there are times where patients might exhibit on a random single occasion, a behavior associated with a higher level of consciousness and then never show it again. So they are related, They are essentially one sort of continuum, but there are distinct steps. The other thing is just to point out these other conditions down below here. We're not really going to be covering these in detail today. I will touch on them at times, particularly when we're doing the comparison across conditions, but they're important for you to be familiar with and have an understanding of their clinical presentations because although they are not disorders of consciousness, their clinical presentation often mimics one, and so these are the conditions that are often misdiagnosed for a disorder of consciousness. This is a graph that came from a fact sheet on the Model System Knowledge Translation website. It's called Facts About Vegetative and Minimally Conscious States. Dr. DiTomaso is going to talk more specifically about prognosis, but what I want to highlight here is just the variability in recovery from these conditions. Speaking to what we were just talking about before, some patients will wake up from coma very quickly. They'll have a very steady and fast recovery, and it is almost as if they jumped straight from coma to consciousness with a maybe period of a day or so between where they're in a fuzzy, minimally conscious or minimally responsive state before emerging into a state of confusion, but clearly aware. Then on the other hand, you have many people who just fall middle of the road where they do make recovery over time, but it's just not quite as rapid. These are the majority of cases that we're talking about when we think about this typically stepwise process that people take through the stages. Well, they're not really stages, through the conditions, I'll say. Then unfortunately, you do have a subgroup of patients that do have a relatively flat recovery curve over time. Also of note, there is significant variability in the range of functional and cognitive outcomes that we see in these patients with some being able to improve to the point of regaining independence in many domains of functioning, whereas others might remain in a vegetative or minimally conscious state for a very long period of time and in some cases permanently. Just to talk about each condition briefly, coma is the obvious one. This is what we all see on TV and what everyone thinks of when they think of a disorder of consciousness. The patient presents like they're in deep sleep, they're unresponsive to anything in the environment around them, no evidence of awareness of themselves. If they do respond to stimulation, it is typically through whole body postural responses or may not even be visibly detectable except in minor respiratory changes or facial grimace, blood pressure, or even galvanic skin response changes are the only detectable response. This condition though, this is one of the biggest misconceptions in the entertainment industry that I think poses a tremendous problem for us on the clinical side of the street, is that it really rarely lasts more than one month, really rarely lasts longer than two to four weeks tops with in the state of a deep coma. Admittedly, I'm going to embarrass myself by admitting that I happen to watch a particular soap opera that I've watched my whole life and I just can't quit. At least once a year, they put a patient in a coma and they'll be in a coma for months, sometimes for a year. Then the patient wakes up and they have no muscle atrophy, no weakness, no contractures. They didn't have any equipment attached to them. They have no cognitive impairments and they go back to resuming their previous life. Unfortunately, a lot of families think they see their loved one in this state or even in the emerging from states where arousal improves a little bit. They're literally thinking of it as a waiting game until their loved one just wakes up and can resume their life. In real life, if you were actually to be in a coma for a month, your chance of survival would be minimal. Usually, you progress to vegetative state or again, higher levels of functioning. The longer you are in a deep coma, the more likely it is that when you do emerge, you're going to emerge into a vegetative state as opposed to having a good outcome at all. Vegetative state is the next level. We are trying to move away from the term vegetative state, oops, moving towards the use of the term unresponsive wakefulness syndrome instead. The reason for that is the term vegetative state was used initially to capture the idea that the distinction between coma and vegetative state was that the presence of vegetative functions started to re-emerge or start to restabilize. As I'm sure many of you have heard in everyday life, many people use the term vegetable to represent patients who are essentially vegetative and think that vegetative means that they are a vegetable. That's an unfortunate negative connotation and not very sensitive and not really accurate. Another reason it's not accurate besides the fact that that wasn't really the intention. Even the term vegetative doesn't fully capture the condition because we're learning that many patients still have significant difficulties in regulating these vegetative functions even when they're in the vegetative state. This is where storming and other difficulties with orthostatic hypertension and central fevers and all these other complications that we come into is because even though there has been some regaining of vegetative functions in the vegetative state, there's still significant disruption to those systems. Even though the vegetative state is not two different levels, it might be helpful to think about it in terms of this explanation. In my mind, I think of it as at the low level of vegetative state, the patient is really not much different than a comatose patient. The only difference might be that they open their eyes and that doesn't even mean that they keep their eyes open all day. It just means that they periodically open their eyes. However briefly, as soon as you start to see eye opening, immediately the patient is in vegetative state. There may not be any other detectable difference in the patient's responses, but as the patient stabilizes, if you do see an improvement, it might be in the range of responses that you see generalized. I mean, in the range of stimulation that you see generalized responses to. In other words, they may start to exhibit startle reactions to loud noises in the environment, or they may start to have pupillary reactions and close your eyes if a light is shined in it. Ultimately, quote unquote, at the higher level, as the patient improves, they still are responding from a reflexive level. Still no evidence of awareness of themself, awareness of the environment, no ability to communicate, none of the behaviors are purposive, but those reflexes go from maybe being a whole body postural, like an extension posturing, or to maybe a localized limb withdrawal, a single limb flexion withdrawal. Also, you may see instead of just a startle, you may get eye turning or head turning towards the location of where the noise is in the environment. Again, still reflexive, but at least it's starting to show that the brain is processing to some extent where specifically the reflex should be, as opposed to just the whole body responding. Criteria for permanence, and again, I'm not going to get too much into the technical details of prognosis because that's for later in a later discussion, but I want to highlight the significant difference in projective outcomes, or I should say recovery timeframes really more accurately, based on the nature of the injury. If you've had a TBI, you have the wiggle room of a year before your condition is considered permanent or chronic, as we are trying to shift terminology in respect to this as well. However, if you've had a stroke or cardiac arrest and had hypoxic injury, the condition is considered permanent after three months. This is the data with respect to factors that relate to not only the complications that occur in traumatic brain injury, but just in general, the nature of non-traumatic injuries, which at least the current state of the science has not let us really distinguish between stroke outcomes and anoxic outcomes, tumor outcomes. All of that is lumped together. Unfortunately, based on where we are now, maybe three months is an underestimate for certain types of non-traumatic brain injuries, but there's not enough research to categorize within the NTBI category, non-traumatic brain injury category. On the more lenient side of the street, which most of us, I think, clinically would lean towards, we would say three to six months before considering a condition permanent or chronic from a non-traumatic injury, but it is a concern because as a result of these differences and as a result of that three-month mark that is arbitrarily common knowledge at this point, people often use the term persistent vegetative state or permanent vegetative state. At that three-month point, regardless of the individual circumstances or the particular injury or the projected prognosis, this is problematic for many reasons. Number one, although most people will remain in a low-level state if they are still vegetative or at three to six months post a non-traumatic injury or if they're still vegetative post a year after a traumatic brain injury. However, there is research out there that shows a substantial minority of individuals will recover consciousness outside of that time window. One study showed that approximately seven and a half to eight percent, again, not a huge percent, but a percentage that is quantifiable, recovered consciousness after six months and that was in a group of non-traumatic brain injuries. Also, it's not uncommon at all to see late transition from unresponsive wakeful syndrome into MCS. In one study, it showed that for patients who were still not following commands and still vegetative slash unresponsive wakefulness at one year post traumatic brain injury, they emerged somewhere between one year and to five years post injury. Granted, most of those patients, if not all of that particular subgroup of late emergers, likely remain severely disabled, but the fact that these patients exist alone makes the term persistent or permanent less meaningful. Also, another big problem, as I said before, is the tendency to apply it incorrectly to not take into consideration the factors that really are important in determining prognosis beyond time that the condition is and also more globally applying that term to any patient who has a disorder of consciousness, including those who are higher level like minimally conscious or even minimally conscious plus. The potential consequence of that is that a patient who might have a recovery outcome is not going to be accepted or even referred or considered for any kind of intervention or restorative rehab if they carry that label of persistent vegetative state with them. Ultimately, there's no clinical difference between a patient who is PVS as opposed to just straight vegetative state. The recommendation is that not only should the term be discontinued, but that it be replaced with the use of chronic vegetative state or chronic MCS, as well as indication of how long they have been in that state and what the condition is due to. In other words, it's much more meaningful to say that a patient is in a chronic vegetative state eight months post an anoxic injury because we already just realized that we know that it's permanent after six months tops. We know outcomes in general are, which will be discussed later, but globally, I think that it's fair to say outcomes are typically better in TBI as opposed to non-TBI with DOC recovery. The time that the patient is in the state is also most meaningful. Eight months post an anoxic injury and still in unresponsive wakeful syndrome is really meaningful if I'm seeing that. If I'm just seeing this patient is PVS, that doesn't tell me anything to help inform care decisions, prognosis decisions, or even my understanding of this patient's care needs. After vegetative state, there's minimally conscious state. As I said before, this used to be a single condition, but more recently was subdivided into minus and plus. The main criteria for MCS in general is that there is inconsistent but definite reproducible evidence that the patient is aware of either themselves or their environment. Inconsistent is key and so is reproducible. Inconsistent is to be expected in any patient with a disorder of consciousness, even that one who's on the verge of regaining full consciousness. Reproducible is important because if you remember when I was talking about the continuum, I said, however rare, it does happen that a patient sometimes will exhibit a behavior of a higher level of awareness and then never reproduce it ever again. The reproducible piece is really important in order to have a level of confidence that the patient is actually conscious and not that there was some kind of blip in the system that let connections magically happen in a patient's brain that really didn't reflect consciousness, might have reflected electrical activity or subclinical seizure or something like that. The main distinction between the minus and the plus is really in the presence of evidence of some kind of language functioning. At the minus level, the behavior, well first of all at all levels of MCS behavior is simplistic but particularly at the minus level, behavior is still primarily subcortically mediated and automatic in nature and so you'll see things like if the patient has an itch on their face, they'll scratch it. If an object is placed in front of them, they'll reach for it. If you go to shake their hand, they may reach out and shake your hand. They may attempt to withdraw, remove a noxious stim that's applied but all of that is spontaneous and automatic. In order to get the plus, you need to be able to attempt to communicate or be able to follow commands, something that indicates the movement towards regaining language functioning. Then in order to be considered emerged from a minimally conscious state, you need to either be able to have functional communication or functional object use. Functional communication means that you are able to communicate either through gestures or through verbal communication but responses must be accurate, reliable, and consistent. Then functional object use requires the ability to use two different common everyday objects like a brush to brush your hair, a spoon to eat. In order to be officially deemed as emerged, you need to demonstrate these behaviors across treatment sessions before the emergence criteria are officially met. Just to quickly go through some comparison of clinical features, I'm not sure if you guys are getting printouts of the slides. My thought was that you would and then these could be cheat sheets or teaching tools that can aid differential diagnosis in clinical practice. Just to touch on for a second the other conditions that I said we weren't really going to get in detail, I will just briefly say that akinetic mutism, which is the AKM, at the low level is essentially synonymous with minimally conscious state but at the higher level is really a severe drive state disorder in which the patient meets criteria for minimal conscious state because behaviorally they're not demonstrating as much as they can because their initiation and interaction is so limited. But upon a certain type of prompting and certain types of tasks, you could see that there's a higher level of consciousness than in the minimally conscious state. A lot of their presentation is going to be the same but ultimately they have likely a somewhat higher level of awareness than the MCS patient, at least at the higher end. Locked-in syndrome is a condition that is traditionally caused by bilateral pontine infarcts and essentially is a diffuse paralysis of all parts of the body except for vertical eye movements and so the patient is fully conscious but doesn't really have any way to demonstrate that consciousness behaviorally outside of eye movements. CMD is cognitive motor disorder and this is a newly discovered condition that really was only discovered through the advent of using functional neuroimaging and more advanced electrophysiological measures to study consciousness. What has been shown in more recent research is that 15 to 20 percent of patients who have a DOC actually present with CMD and so what is that is important. Basically, it's cognitive motor dissociation. Another term that you may be more familiar with is covert consciousness and essentially it's damage to the functional integrity of key pathways that allow for communication throughout the brain so that in theory you can have all the structures intact but if they can't communicate with each other then there's no way for the patient to be able to translate intention or thought into action to allow them to behaviorally demonstrate their awareness. It may be that there's disconnection between the thalamus and the higher level sensory and motor centers. It may be disconnection between the higher and lower motor centers but ultimately there are also likely other areas of damage so it's not like a picture perfect scenario like with locked in where you could say they are a hundred percent conscious. They're not but the essence is that they are significantly more conscious than they can demonstrate on behavior exam. They most often present as vegetative on exam and their consciousness is only detected when they go for neuroimaging studies and they see that the patient can follow commands and may even be able to communicate functionally through brain activity. So this again is just an overview of the different reflexive and purposive responses as you graduate through the levels and just as a comparison to see in that CMD the global motor impairments are really the primary issue and depending on the nature of the injury there is some variable preservation of ability to process auditory and or visual information through brain activity. Finally emotion and communication and just touching on the akinetic here too. This is usually one of the big things in that the patient is more likely to be able to communicate and not just communicate through gestures or yes no they often can communicate answer questions about their personal history but they have a very low volume. They don't have initiation for speech. If they speak it's maybe single words but their responses tend to be more accurate than the ability to communicate seen when a patient is still minimally conscious. So moving on to assessment ultimately obviously I should say the ultimate goal of assessment is to obtain an accurate diagnosis. That's number one but beyond doing that especially if you are monitoring a patient over time assessment really provides us with a way of monitoring a patient's performance over time and by having data that we can collect on a regular basis it really puts us in a position to capitalize. You know we could say about any rehab it's the notorious question of really what facilitates recovery. Is recovery spontaneous or does rehab actually create recovery and you know I don't know that we'll ever actually know because it's probably some sort of synergistic process but even if we want to argue for sake of argument that recovery from disorder of consciousness happens spontaneously and it did not matter what we were providing them. The ability to track patients in a structured and systematic way allows us to detect that very first sign of emerging awareness so that the patient can have access to services and access to rehab and timely interventions which will obviously promote functional recovery. On the other hand or the other side of that same coin is that by monitoring them in this systematic fashion it also sets us up nicely to be able to detect compounds that might be suspected to be interfering with our assessment. So again going back to the CMD example the earlier that's detected if it could be detected in the ICU or in the very acute hospital stay that's going to significantly impact that patient's whole future. If it gets missed in the ICU level that patient is going to be diagnosed as vegetative and may have no access to any care even though they're fully conscious. So that ability to facilitate detection of those compounds that can really make a difference and not just compounds that are patient driven as far as the injury but other things that might be treatable like infections, seizures, other complications that we know can totally deteriorate a patient's status and can totally not just set them back but can change their trajectory that having that structured assessment allows for early detection of those issues so that we can address them in a more timely fashion. So regardless of the tool that you're using or whatever approach to assessment you're taking when evaluating a patient with a disorder of consciousness the key is to assess each of the sensory domains and also to capture the range of behaviors from reflexes up to cortically mediated responses. So at the most basic level an assessment of visual functioning would look at cranial nerve functioning including especially the oculomotor nerves and pupillary responses and then on the more cognitively mediated side of the street the ability to fixate and track visual stim and at the higher level be able to identify and discriminate visual stim. Auditory functioning it's the same thing you have your basic reflex testing and on the higher end it would be following commands or responding to questions. I just want to point out here that among the many compounds that we see in this population particularly with traumatic brain injury it's important to rule out hearing loss because of just the frequency of those pathways getting damaged. So it's not uncommon to have blunt trauma or other injury to the middle ear which can lead to conductive hearing loss and temporal bone fractures are also very high frequency in TBIs and those fractures can damage the auditory nerve. So that's just one of the examples of something that needs to be looked at as part of the basic evaluation. Motor functioning you guys can probably speak to much better than I can but basically we're talking about not only the basic reflexes and grading whether they're hyper or hypo tone, hyper or hypo reflexive but whether really the motor impairments are often a major impediment to patients being able to demonstrate their consciousness. So understanding or sharing with the team whether the patient is flaccid whether spasticity contractures or even more not direct brain injuries but more bodily injuries like broken limbs and things might impact on the ability to assess the patient and the patient's ability to respond. One because often the patients who are doing the assessment I mean often the staff who are doing the assessments are not necessarily especially of consciousness may not be PT and OT may be more like speech therapy or psychology who you know might not be as knowledgeable about the risks of say trying to range a patient to a severe spasticity or a severe contracture. So both for the safety of the patient and also to help inform that whole process of detecting confounds and evaluating a patient's best mode of output the physiatry and physical domains of rehab are really key to that process. And then active movement is another thing particularly as a patient starts to have resurgence of movement determining whether that is just spontaneous and random or automatic or whether they're actually following commands that it's intentional and speech and communication also same idea as far as the range of responses for sake of time I'm just going to move on from here. So true or false, the most reliable and accurate way to diagnose a disorder of consciousness is by conducting a bedside eval. I'm going to play a little bit of a game here, just in your mind. False. So in fact, informal bedside evaluations are prone to a very high rate of misdiagnosis. And even what was previously the gold standard, which was team-based consensus diagnosis, carries with it over a 40% error rate. So the reasons why are many. First of all, the presence of arousal difficulties, overlying complications, overlying issues with reflexive behaviors that make it difficult to distinguish from purposive behaviors. Examiner error is a lot of reasons. But we don't really have a lot of control over the reasons that are patient-driven. But we can influence the examiner error by using standardized assessment scales to try to reduce diagnostic error and improve diagnostic accuracy. So ultimately, we want to use reliable and valid scales, as opposed to informal one-off bedside evaluations. And the reason for that is not only does research support it, as Brooke touched on earlier with respect to, at this point, the CRSR being the main gold standard at this point, but also these scales, as you can see, have built-in measures to aid in ensuring that you're diagnosing accurately. They also have standardization procedures, which are key to making sure that you're not just taking a one-off approach to evaluating different functions. So a couple of things to just quickly point out here are that you'll see all of the sensory domains are covered. The items are hierarchically organized. And the coding system, which on the scale sheet itself has symbols, but I've highlighted here in colors just for sake of you being able to see, are really the items that translate to clinical diagnosis. So you do get a total score, but the total score was not designed to translate to a clinical diagnosis. Its utility is more related to maybe being able to track over time. But the essence of the scale is really being able to look at progress in each of the domains, and in particular, to be looking for the presence of any of these behaviors that have these key codes to them that their presence would translate to one of the diagnoses on here. Also, the newer version, which just came out in 2020, includes a test completion code section, which allows, again, another level of being able to aid in the detection of confounds or other complications that might make it not possible for the patient to perform a particular item or subscale, so that it's not held against them as something that's misunderstood as being something they can't do. Maybe they had a sensory deficit that limited them. So true or false, when using standardized scale, it's possible to assess accurately on a single assessment. Again, that's not true. Even though we're using standardized scale, we want to give them many times. There is a lot, again, of variability, uncertainty, and responses going in and asking a patient one time to do one round of a CRS when the patient is not maximally aroused, let's say, is not necessarily going to give you an accurate diagnosis. And this group of researchers did some research showing that behavioral fluctuations within the patient's performance impacts diagnostic accuracy up to the fourth assessment. And so they recommend doing a minimum of five assessments over a short period of time before coming to a diagnosis, emphasizing the need to make sure that you're repeating and that you're repeating with the frequency that is specific to what the patient's needs and circumstances are. Obviously, early post-injury, when there's a lot of rapid changes occurring in the patient's status, we need to be monitoring them and assessing them much more frequently than we do when they're a year post-injury in the chronic stage and they are more stable and maybe just being re-evaluated, need to be re-evaluated periodically to make sure there has not been a significant change. So some general guidelines when thinking about how you want to structure your team or who is going to be the people administering the scales and how these schedules are made. Ideally, you have multiple staff who are trained to use it. Ideally, multiple disciplines. And like in my facility, we have the speech therapist, the cognitive therapist, and the neuropsychologist who all do the assessments. But they each pair up with OT and PT, cognitive and neuropsychology or speech, to also assess the patient at different times of day when they're in the PT gym and the OT room in different environments to try to not only make sure they're maximally aroused, but to see what environments elicit the best responses for the patient. Dr. O'Brien is really going to touch on confounds. I just wanted to highlight here. So visually, you could see how many common problems that overlie these patients. And that really, it's the rule, not the exception, that they're going to have at least one, and more often than not, more than one of the items on this list as a confound that needs to be taken into consideration. So the holistic approach is that the assessment scales are one piece of the puzzle. They're an important piece. But they're not the only piece. Also needs to be taken into account careful history, including some of the factors that we talked about with respect to the guidelines and the factors that influence recovery time frames, like nature of the injury, recent neuroimaging studies, as well as in cases where responses are ambiguous, sometimes more sophisticated neuroimaging studies. So when there remains ambiguity, the recommendation is that multimodal evaluation should incorporate functional neuroimaging or electrophysiological studies to try to detect awareness. And not everybody has access to this, really mostly available in research centers. But if you suspect your patient is more aware than they're demonstrating, then it is recommended that you try to get them into some sort of study where that can be evaluated further. So ultimately, we're looking at standardized behavior assessment with a validated scale, the gold standard being CRS. Objective tests, which under normal circumstances might just be your typical CT, MRI, EEG, other studies along those lines. And in cases of extreme ambiguity, you might want to consider incorporating more sophisticated or advanced neuroimaging studies. And also, don't forget about the importance of qualitative information. The family, they're often the first ones to see changes that we don't see. They should be considered as part of the care team. They can be really integral in detecting first signs of either emergence or a problem. Also, your nursing staff, your rehab staff, anybody who interacts with the patient should be part of the communication stream when trying to determine with certainty one's diagnosis. Last notes are just related to the idea that you can use serial assessments for more than just diagnosis. Also, as we alluded to earlier, collecting the data over time helps inform prognosis. And just to sort of show a difference between two images, this would be a patient who, this is a case of a patient who is a TBI, who came in in a vegetative state, and about two months post-injury, who made rapid improvements and then stopped progressing. If we didn't have this later data here, maybe you'd say that he had plateaued. But if we take into consideration everything we know with respect to, he's still well within his window. He was making rapid gains up until that point. He was traumatic brain injury. More likely than not, this is one of those cases where this flatline represented a potential confound. And in his case, he was developing pneumonia here. And then once it was treated, he continued on his positive recovery curve, as opposed to our other example, which shows a patient who is anoxic eight months post, who's still in vegetative state and varying only between a four and a six, which is really still very vegetative. And now he is in his chronic stage and still flatlines, essentially. So you can see the difference in how you might judge those outcomes to be. So this just summarizes the utility of serial assessments with respect to monitoring recovery, response to intervention, being able to detect emerging problems or improvements. And that wraps up my portion of the talk for today. Pass it over. I'm sorry for the delay with the technical issues. I'm Greg DiTomaso. I am the medical director of Persecute Medical Rehab Hospital and the director of Early Career Physician Development for US Physicians. I'm going to try and keep my chat up. So please feel free to jump in, ask questions, and keep me on my toes. I do have some disclosures, as mentioned earlier. I'm going to speak for exobionics. So I think the first thing I'd like to just get in everybody's mind, if you can, is to think of brain injury and think of it always as being the same process. You have a brain injury. You enter this coma period. Then you have progression through vegetative, minimally conscious, and post-traumatic amnesia and recovery. And that's no different whether we're talking about the mildest concussion-type brain injury, the loss of consciousness, to the most severe injury. The question is just the speed at which people progress through that. And some individuals seem to spend more time or get stuck kind of in that. And that's all we're really talking about. So I just wanted everybody to kind of reset and think about it from those perspectives. Because whether you're used to dealing with concussions, moderate or severe brain injury, you know this stuff. And if you're a physiatrist, and you're board certified, and you're well-trained, none of this will be a surprise or a new thing. So just to break it down and get to the basics again, when we talk about consciousness, what do we mean by that? Well, we mean someone who's kind of aware of something, that they're interactive and they're engaged in something. And then, of course, there's other sub-meanings. But scientifically, when we talk about consciousness, we're talking about people who have both arousal, the ability to wake up, and awareness. And that's where we get stuck, right? This arousal, this ability to kind of wake up, that's what's lost sometimes. And so that's oftentimes with patients with severe traumatic brain injury you're dealing with. Or is it the second part of that, the awareness, realizing what's going on around them, being able to interact with themselves or the environment. So when we're looking for consciousness, we're looking for both of those things to be present, the ability to wake up, to have arousal, and then the ability to interact with themselves or the environment. So just to make it super simple. So we talk about that coma period, and Dr. Rosenbaum did a fantastic job of outlining that. We're talking about a very time-limited period of time, a very time-limited duration, coma. And again, we're talking about no arousal, no ability to wake up, but also no awareness, no interaction with the self or others. We wanna be a little bit more scientific about that though. We look at an EEG and we define coma as not having real evidence of a sleep-wake cycle. If you do a prolonged EEG recording, see the kind of sleep-wake cycles. Not that it has to be perfect, like someone who doesn't have a brain injury, but that you don't really see any organization to that at all. And for this damage, we're always talking about damage to the reticular activating systems. You can get there with severe thalamic damage, but it's pretty rare. Then after that, we move into the vegetative state. And again, Dr. Rosenbaum covered that in more detail and more thoroughly than I ever could. But what we're really focused on here is we're regaining some ability to have that arousal, to wake up and to turn the eyes on. And scientifically, we're defining it by resuming some type of sleep-wake cycle. Again, it doesn't have to be perfect, and that doesn't hold 100% of the time, of course, but that is the way we scientifically kind of look at that. And then finally, minimally conscious. And that's, again, where there's definite interactions with either the self or the environment, but it's inconsistent and it's not robust. And again, Dr. Rosenbaum can cover that very, very well. So if you have questions on that, please chime in. That's the only way I can really know whether you're understanding this. If not, we're gonna move on because you have a lot to cover in a short amount of time. So as we emerge from minimally conscious state, we begin to have more consistent, more reliable interactions with the self and others. So we're starting to see things that we can define as being clearly conscious, clearly indicative of an improving level of arousal and awareness within this individual. And again, best demonstrated by the JFK Coma Recovery Scale. Here's a slide I directly stole from Dr. Giacino. He would approve, I think. And you can see, based on his work, and you can see based on various behaviors, what we expect in each level. Now, again, nothing holds 100%, of course, only the Sith speak in absolutes, but there's some axioms here to take home. As we move forward tonight, there's two texts that really influence what I'm going to tell you. The first one is the practice guidelines, and that's what the talk was named after. Again, as Brooke covered, this was the, Dr. Murtaugh said it was a collaboration between the American College of Neurology, American College of Rehab Medicine, and NIDILRR. I'm also going to highlight just a little bit, the minimal competency recommendations, just because, as I said, I've been part of three different disorders of consciousness programs, and I think fulfilling the minimum competency guidelines, that is the very minimum that those programs have to offer, is important if you're interested in this work. All right, so let's talk first about TBI-specific neurological sequelae. So these are things that come up along with the TBI that often make assessing the patient more difficult. So number one, I think Dr. Rosenbaum covered, to some degree, locked-in syndrome, and this is clearly not a disorder of consciousness. It's something that is sometimes mistaken for a disorder of consciousness, but it's not the same. Again, we're talking about severe brainstem injuries, and it's almost like a spinal cord injury so high that the individual can't even move their face and other muscles. But the eye movements are what you're really tracking here. So please pay attention to those if that's in the differential. There are some caveats you need to take home from this talk, primarily that you do need to reassess them frequently. Damage to the cranial nerves is not uncommon, so the eye movements may not be perfect. Ophthalmoplegia is also common, and visual impairments are often common. So just because the eye movements aren't perfect, just because the exam isn't exactly consistent or great does not mean that you're not dealing with locked-in syndrome, and I can speak from personal experience, man, the fatigue on these patients is phenomenal. So if the exam in the morning is really good, you're probably not gonna get another good exam the rest of the day just because you're going to be too tired. So please factor that in when you're considering these patients. For management, again, frequent reassessments, I think, are essential. You can try the blinks. I'm not a huge fan as people blink for lots of reasons, obviously. So you're not always getting the accuracy that you want with that, but it's one way to do it. Removing the eyes in different visual fields is often helpful, and picking between a yes and no with eye movements would be my preferred way of interacting. Education on how to manage these patients is essential, and there was a great article published in PM&R maybe four months ago. It had some great tips and outlines. And then augmented communication devices are the name of the game here. Using those eye movements to dial in and spell out words and so forth unlocks the true potential of the individuals. All right, moving from that to something you will see in this story of consciousness common often is hydrocephalus. And I'm a big believer that hydrocephalus is extremely common in this population. Remember that hydrocephalus can kind of come in three flavors. That is the classic elevated pressure hydrocephalus, normal pressure hydrocephalus, and ex vacu hydrocephalus. My caveat there would be that my experience tells me that these often overlap. It is not uncommon to have elevated pressure and normal pressure or ex vacuo and elevated or normal pressure. And so just because you have identified one of those doesn't mean that you're not dealing with the others. You can find anything you want in the literature between five and 85% plus or minus 15, and they probably got it. In the work that I helped to contribute, we found it in 38% of patients with disorder of consciousness and assessing for this is part, the ability to assess for this is part of the minimal competency guidelines recommendation number eight. So if you do a neurology residency and you look at these patients, they're gonna tell you that you're looking for gait abnormalities, cognitive changes, and urinary incontinence. However, if you're dealing with a disorder of consciousness patient, then you should not be walking. Cognitive changes are pretty tough to elucidate and urinary incontinence is occurring with every patient. You can try a lumbar puncture. Again, from my experience, I've never found that this was particularly helpful. Sometimes a lumbar drain will be a little bit better, but you really just kind of have to know it when you see it. And here is an overwhelming case of hydrocephalus from my perspective. It is true that this person has some brain atrophy, as you can see, but ultimately shunting helped their consciousness tremendously. So I think the read was correct. And then again, we'll come back to this study, but this is a relatively famous study where they show covert consciousness in a patient with a vegetative state. And I would just ask you to consider that perhaps this patient really didn't have covert consciousness and really wasn't in a vegetative state. Perhaps this was just untreated hydrocephalus. As you look at the size of these ventricles, they're really, really massive. Management of hydrocephalus is pretty straightforward. You put a shunt in them and you titrate the pressure to the appropriate pressure for that patient. Every patient is different. There is no guideline tool that you can use other than serial titrations to narrow it down. So you need to be very patient when doing that. And then finally, for those of you who are falling out of your seats because I'm including normal pressure and ex vacuo hydrocephalus in this talk, I will remind you that there are evidence-based cases of patients improving their consciousness after shunting with both of these diagnoses. And I can say clinically, I've seen it a handful of times as well. So just because it's read as normal pressure or ex vacuo in no way means that it's not contributing to the patient's disorder of consciousness. And I still don't have a single question on that inflammatory statement. So I know y'all are probably gonna be tough to arouse, but I'll do my best. Other issues to consider. Again, there are lots of risks and complications related to shunting. So you've got to kind of consider those things and talk them over with the family, the patient, so to speak, and the neurosurgeon. And also again, these patients do need titrated in my estimation because they perform well at a particular pressure today doesn't mean that's their pressure tomorrow or next week or next month or next year. So you've gotta be able to follow them up and titrate that as appropriate. So something to think about. All right. No comments still. All right, moving to seizures, epilepsy. So epileptic seizures in case the audience is not familiar is cortical hypersynchronization, typically high frequency and high voltage. And both partial and complex seizures have been reported to impair consciousness. I know you're thinking, the definition of partial seizures implies that they do not impair consciousness, but dealing with the severe traumatic brain injury or a severe anoxic injury resulting in an alteration of consciousness, it doesn't take much to tip them over the edge. Again, you'll find in the DOC population, the prevalence is reported between 11 and 32%. In my work, we found 29.5%. So right within that range. Again, everyone here probably knows how to diagnose epilepsy or seizures. I'm sure, and that's within the EEG. Remember that you're at high risk for continued seizures if you do find epileptic form spikes bilaterally during the rehab care, but interestingly enough, not during acute care. So it seems to be something about as the person progresses with their brain injury, if there continues to be bilateral epileptic form discharges that's a higher risk. So something, a little caveat to keep in mind. So how do we define post-traumatic seizures? Well, in the traumatic brain injury population, we typically name it one of three things, either an immediate seizure, meaning a seizure that happened at the time of injury, usually not requiring any follow-up, an early seizure happening within seven days of the injury, usually amenable to prophylactic treatment, and a late seizure that occurs more than seven days after seizure and typically needing ongoing epileptic management. So post-traumatic epilepsy as a term is typically defined as seizures that occur after seven days. An AAN guideline is to perform prophylactic anti-epileptic medication to prevent seizures. It is level A evidence. It has been confirmed with multiple randomized control trials. Prophylaxis is not recommended, however, for late seizures. So after seven days, you can wean off. There are some risk factors. Patients to keep in mind may be especially high risk for seizure. And of course, severity of trauma is the second bullet point. So most of the people who we're talking about in this cohort will automatically qualify as high risk. Still, I typically do wean seizure medicine after seven days and recheck if I'm concerned that there's ongoing seizure activity. Risk factors for early seizures were alcohol and young age. Risk factors for late seizures are, of course, old age. And by that, we're talking over 65. And every year, that seems a little less and less old. Here's a potential flow chart that you can use to decide who needs treatment and who just needs prophylaxis. Perhaps this is helpful to you if you're unfamiliar with it. And again, my practice has been to do antiepileptics for one week and then wean off. Although a bit controversial in reviewing the literature, I do feel like levotiracetam and phenytoin are equivalent. And given the potential side effects and difficulty in maintaining a phenytoin level, I almost always go with levotiracetam. And then again, you have to really be mindful in this population that antiepileptics do cause sedation, slowed learning, attacks via behavioral changes, and can dissipate to allergies. So when possible, please consider weaning. Causes in this case, we're talking about severe traumatic brain injuries. So we have that down. And appropriate dosages, side effects is beyond the scope of this lecture. So we will avoid it. Weak evidence that limotrigine or oxycarbazepine may be less sedating than levotiracetam. So when stuck, rotating that is a reasonable option. But there is no real evidence to suggest that a particular antiepileptic is appropriate in disorders of consciousness. All right, moving from seizures. Since again, nobody has had a question, we will go into paroxysmal sympathetic hyperactivity. You may, if you were taught the way I was, just call this storming. However, you should know that this etiology has many names. And if you were to do a literature review, unfortunately, you would have to search all of them. It has been reported between 26 and 34% of the DOC population. There is actually a criteria to diagnose it, although I think as has once been said about pornography, you typically know it when you see it. If you need a checklist or that kind of structure, here it is. All righty, and management of this is typically around medications that can help to alleviate it. When I was teaching residents and fellows, I was taught them to think of storming as similar to autonomic dysreflexia and spinal cord injuries. The first thing you should do should not be to throw a ton of meds at them, but to look for an underlying irritant. If there's a UTI, an ingrown toenail, a fecal impaction, those things are much more likely to predispose the patient to storming. Only if you've kind of eliminated those irritants do I start throwing meds at it. And of course, when I'm really desperate, intrathecal baclofen, in my opinion, is by far and away the most effective intervention. It is difficult taking an early TBI to the OR for another procedure and to implant intrathecal baclofen when typically the guidelines would be to wait six months. But when the storming is severe enough, I've done it a handful of times, and it's been very effective. Multiple studies indicate that storming is not a prognostication factor for DOC patients, although to get back to Dr. Rosenbaum's point, I do think that it probably extends the window for those patients a little bit, because while you're looking for them to improve, if they're storming, they're not going to improve. So it may allow you to cushion that prognostic window of when you're looking for improvement. Again, there are case reports of intrathecal baclofen decouraged from storming, and I could add a few if I had the time to sit down and write them up. And it's unclear if storming improves consciousness or it simply allows more accurate assessment. So I will say that it's still up in the air. Next, we'll move on to neuroendocrine abnormalities. There's, again, no questions from anyone out there. So neuroendocrine abnormalities certainly have been well-documented within the severe traumatic brain injury and more recently within the DOC population. In fact, recent work that I was lucky enough to participate in found 8.2% of the patients had an element of hypothyroidism. So we have no epidemiology for growth hormone. However, 65% of one severe traumatic brain injury sample had a deficit. So these hormone abnormalities probably exist. Again, there's lots of reasons that that might happen, given the fragility of the hypothalamus pituitary axis at the bottom of the skull in these severe traumatic brain injury cases. So I do routinely check TSH and T4 and T3 in my severe traumatic brain injury patients with disorders of consciousness, and rarely will check a growth hormone if I just can't figure it out. If there is an abnormality, I do not hesitate to add levothyroxine. We add lots of neurostimulants in my practice anyways. Levothyroxine, in my mind, is just another one. I rarely add growth hormone unless I am fairly confident that that's contributing to the patient's lack of progress and the family has the means with which to continue the intervention, as it is quite costly and rarely covered by insurance. I have a question. Shoot. Hi. I am wondering about the timing of when we would see these abnormalities. Is it something that you could anticipate manifesting shortly post-injury, or you would develop suspicion for further down the line? So I think that's a nuanced question, and I don't mean to sidestep it, but it really depends upon the degree of severity. We know that some changes in the thyroid are normal when someone's sick or injured. So I will even go as far as to get reverse T3s and reverse T4s at times to assess that, and even an endocrinology consult if I'm stumped. Clearly not my area of expertise. So if I'm concerned that something's going on, I involve them early. If the TSH is like 50, you know that there's a problem. It doesn't matter if it's a day, a week, or a month after the injury or six months. You know, if the TSH is like seven, then I think it's a much more difficult question to answer. And so you've got to kind of take that with a grain of salt, right? Same thing with the growth hormone. Although the national standards are not there, if it's undetectable, clearly there's a problem. If it's just out of what your lab is reporting as the normal range, then it's really difficult to interpret. You've got to think about whether it's worth treating it. This is something that you'd be testing for at the outset, then? I don't ever think there's a wrong time to test for it. It's just provided that you have a plan for what you're going to do with the results, right? If someone's in a disorder of consciousness and they're not improving, checking TSH, I think, is very reasonable. Just know that, hey, if it's a little bit abnormal, do you really want to go down the rabbit hole of working it up and treating it? If it's grossly abnormal, are you prepared to treat it and to be that person? It depends a little bit on your setting, your interaction with your consultants, and so forth. I don't think there's a wrong time. No one has definitely established criteria on what the right time is. You really get to trust your gut on that one, so to speak. I'm going to move on, unless you have a follow-up question. No, thank you. Okay. Lastly, I think I got to talk about catatonia. I know this is a bit of a wild card for some of you, but I have become friends with some people in the field who have really opened my eyes to this. Catatonia, we typically think of as a psychiatric disorder, something that maybe not related directly to traumatic brain injury. If you look at the literature, in many retrospective studies and case reports, there was a clear traumatic brain injury before an episode of catatonia. There may be something with neurologic dysfunction that predisposes certain people to this that we haven't fully elucidated yet. In the research that came out of Tier Memorial Hermann with my colleagues, we actually felt that there was a catatonic contribution to 4% of our TBI disorder consciousness patients. Data on the prevalence in all populations is relatively poor, so that's all I can go on for this talk. Again, the catatonia is a psychiatric diagnosis, so it is outlined in the DSM-5 or whatever number we're on now. Unfortunately, this checklist really doesn't work for a patient with disorder of consciousness. You do have to rule out neurolectic malignant syndrome as these patients are on lots of crazy drugs oftentimes. The cool thing, I think, is that catatonia is treated with the same drugs that have been published to improve symptoms of disorder of consciousness, perhaps either elucidating a common mechanism or maybe patients have been misidentified in the past. But looking at patients who improve on lorazepam and zolpidem, especially zolpidem in the DOC population, has some evidence, and there is a case report of midazolam. So it is an interesting crossover to think about, and I would encourage you in your TBI practice to at least keep it in the back of your mind. All right, so from there, we're going to move a little bit into prognostication. Hopefully, you can identify some of those confounds we talked about and focus purely on the brain injury or the anoxic brain injury in front of you and not deal with the confounds too much. Again, I like this chart originally published in Current Opinions in Neurology. It shows that typically the motor responses take off before the cognitive capacity, but this is the typical curve for most brain injuries, and so you can kind of plot where you are on that in your mind. So the first thing when you're trying to do to establish some prognosis is to get as many of these types of things done as possible. Now, I don't think you have to do all of them. In fact, I think a lot of them really are unreasonable, but as much as you can do here, you'll be following both the guidelines and the minimal competency recommendations to really evaluate prognosis, and we'll dive into each of them in a little bit more depth. Number one, I think we need to spend some time on EEG, right? Everybody loves EEG, and you're going to get it anyways because you've got to work up those seizures in these individuals. They're so high risk. It is interesting to know that EEG does predict prognosis at 12 months, but only for the positive. If you look at the study by Clausen, which this recommendation was based upon, they had a very controlled, tightly organized trial where they would present stimulus to the patient and look for predetermined EEG changes. When those were there, it gave a positive prognosis at 12 months for those in the disordered subconscious. When they were negative, it did not have a positive or negative predictive value. When you're working with these patients in acute care, keep in mind that the EEG alone can only give you a positive prognostication. It is not appropriate for negative prognostication if you're following the guidelines. Evoked potentials, I love evoked potentials. They're great. It's hard to get them done sometimes, though. Recently transitioned from high-level academics to private practice. I can tell you that there are not a lot of people in the private practice world or smaller hospitals who are still doing evoked potentials. Again, these are high positive predictive value tests because when they're there, when you can get normal somatosensory evoked potentials or normal auditory evoked potentials, they give you good reliability that the patient will have a positive prognostication. When they're negative, however, they really don't mean much and they don't predict anything. It's only a positive if you can get them done, which is rare. Everybody loves fMRI. Everybody loves a pretty picture. There are lots and lots of studies. The studies used for the guidelines are now probably somewhat outdated. As Dr. Murtaugh had mentioned, they are a few years old now. Again, they're looking at pretty things like this, trying to show evidence of activation deep within the brain when presented with particular stimuli. Again, if you have a protocol with predetermined outcomes, then fMRI may help you determine consciousness without those predetermined protocols, though you're really not following the evidence. Furthermore, anytime I talk about imaging, I have to show this. This is one of my favorite slides in the world. This was an fMRI of a dead frozen Atlantic salmon at University of California, Santa Barbara. Of course, they were able to show that the appropriate signals lit up in the fMRI. Clearly, the dead frozen Atlantic salmon is not conscious. A little grain of salt with the fMRIs because I do not think that the technology is as far advanced as we often like to pretend. All right. All of those things are nice and pretty, but probably not what most of you are dealing with, unless, again, you're at a very high-level academic center. If you ask your average neurologist or neurosurgeon to prognosticate, they are probably going to plug some very basic demographics into the CRASH calculator. The CRASH calculator came from the IMPACT trial. It's more than 10,000 studies. It is a cloud-based database that lots of trauma centers feed into. People love to grab that data and make all big data papers out of it. One thing to notice is that the outcomes are at six months, which is a bit different than what some other researchers look at. They did use multivariate logistic regression analysis, which I am not going to tackle as I am not a statistician. Dr. Rosenbaum and Dr. O'Brien can tell you much more about that. They created two versions of their prognostication model, one that's a very basic model and one that involves CT images. The basic model, you can see the things that were of high weight or age, glass glaucoma score, pupil reactivity, and presence or absence of extracranial injuries. In the CT, you can see all of the wonderful things that have weight in their model. Here's an example of one of these fancy calculators. You can pull it up on your phone or on your computer. You can plug your patient's demographics into it. It gives you a percentage of mortality and unfavorable outcome, meaning glass glaucoma score of dead, vegetative, or severely disabled. I'm sorry, UWS shouldn't say vegetative. My apologies, Dr. Rosenbaum. Of course, let's start with the glass glaucoma scale. This has already been covered. You all know it. You learned it in med school, probably had to memorize it as a third-year student. There are some caveats, however. You're dealing with these GCS scores. If the individual is agitated, which as you know most of these severe traumatic brain injury patients are, it's very difficult to adequately assess. It's not reliable if the patient is intoxicated. If you're dealing with this population, you know that a large percentage of them are severely intoxicated at time of injury. It's not very sensitive for unilateral issues. It does not pick up on spinal cord injuries. It is not accurate after intubation. If you're the EMS in your city or anything like they are in Houston, Texas, you know that everybody comes in intubated whether you really need it or not. Furthermore, pupil reactivity of the GCS score carries a ton of weight on the crash model. There are lots of things that can impair pupil reactivity besides just having a severe traumatic brain injury. I've tried to list as many of them as I could think of here. I'm sure there are a ton more. I think that we have to be very mindful that those initial pupil evaluations are not always accurate for a host of reasons in addition to what I've been able to list here. Now let's dive into the CT findings. All of these things on the CT are bad. They all have a ton of weight and will change the percentage number that your calculator will give you. This is a slide I stole from Dr. Weintraub. He apologizes to everybody for not being here. He was a big part of this talk and unfortunately due to circumstances beyond his control is unable to make it. All of these patients presented to Craig Rehab Hospital in Colorado, all of them had very, very low GCS, three or four, and all of them had pretty good outcomes. As you can see, they all have different reasons why their GCS may have been very depressed. Then, as you can imagine, they all did very good with high intensity Craig-level rehab. Just because a patient has a CT finding, it may or may not confer bad prognostication and will likely confer very different deficits and require very different rehabilitation patterns. It's difficult to lump them in together given that not everyone has access to high-end rehabilitation like the Craig Center. Can we do better? I think we can. I think that if we could measure post-traumatic amnesia, at least in our severe traumatic brain injuries who can interact, we certainly would have a better understanding of prognostication. I will refer you to the GOAT as I am in Houston, Texas and Galveston is just down the street. There is, of course, also the OLAW, which I think is what many people have matriculated to. I'll give you a nice picture of Galveston, Texas. It didn't look like that this morning. For those of you who are unaware, we got hit by a hurricane last night. Luckily, it was a relatively mild one. I think everybody came through unscathed. If I'm a little less energy than normal, it's because I was up all night listening to the wind. The GOAT, for those of you who are unfamiliar, 16 items, max score of 100, and you're out of PTA when you have two consecutive scores better than 75. We know from the GOAT that if we can chart the rate of the time frame it is from the injury to the PTA passes, we can predict the trajectory of recovery with much more accuracy. I love Dr. Rosenbaum's slide, if you saw it, that showed all those different trajectories laid out. That's really what we're trying to get at with prognostication. If you can measure the rate of change, I think you can really start to understand where these patients are going. We'll come back to that later. Just keep that in your left hand for a second while we move on. This is in severe traumatic brain injury. Obviously, this doesn't apply to disorders of consciousness per se. Let's look at the data that's already been collected. If you're looking at prognostication and data on disorders of consciousness, you've got to start with the multi-society task force that occurred through the New England Journal of Medicine in 1994. They looked at traumatic injuries and non-traumatic injuries, and they looked at their progression for three months, six months, and 12 months. They assessed the patient for either death, vegetative state, now we're calling UWS, of course, or conscious. No real, minimally conscious, that delineation wasn't quite there yet. As you can see over time, yes, some patients die as time goes on, but they really don't stay in this vegetative state. That number dwindles in both the traumatic and non-traumatic. The number of conscious patients increases pretty well. Even then, in 1994, without any guidelines or structure around rehabilitation for these individuals, there were good outcomes. These patients did have the ability to recover, even at 12 months back in 1994. Here's this graph. If you look at the traumatic injuries, a lot of them improved their consciousness and got better. They didn't really stay in this vegetative state. Yes, some of them died off, of course, but something to think about. Then came the work within the model systems. For those of you unfamiliar with the model systems, those are 11 or 12, I think it's 11, institutions that have research funding and are encouraged and thought of to have high-level rehabilitation care. They looked at those individuals who came into model systems with disorders of consciousness. When they reviewed those patients, they found that 68% of those who entered the model systems in a disorder of consciousness regained consciousness during the rehabilitation stage. That's a pretty high percentage when you think about it. 23% were able to emerge from PTA. With the proper environment and structure, these patients were able to make rapid progress and even begin to form new memories. Interestingly enough, 68% of those patients were able to be discharged home and into the community. That's the recommendation three from the guidelines to say that these patients really need to be in center so they can be properly cared after because the outcomes just seem to be much, much different. We took that same group of patients and we then looked at them five years. At five years, 72% of the patients, sorry, 21% of the cohort were during the early recovery. Those people who were already following commands were making progress with rehab before they were discharged. At five years after injury, all of those patients were independent for something. Pretty good, right, for somebody who had a severe traumatic brain injury and a disorder of consciousness. 56% were able to do problem solving, not low-level stuff, and 85% were independent or modified independent, whether they were able to walk or wheelchair. Again, these patients did really, really well even if the payoff was five years later. What about those patients who didn't follow commands, who didn't do so well during inpatient rehab? Well, they were able to find 36 of them. They were not following commands. They were still considered in disorder of consciousness at the time of discharge. Five years later, 20% to 40% of them were independent with something. Even though that they hadn't developed the ability to follow commands or to improve their FIM or GG scores back then, they were able to do so over the next five years. It laid the basis for improvement. I see a lot of activity on the chat. I'm going to take a quick break and see if I can catch up. Holly asked me a question about the GOAT versus the Westmead. I am not the right person to ask that question. We'll bring on Dr. O'Brien and Dr. Rosenbaum to answer that in just a minute, as they are the neuropsychologists and would be much more well versed than I am. Then we looked at that same population at 10 years. Of those patients who were able to follow for 10 years, 80% of them were able to walk, 72% were bathing independently, 80% again were able to manage their bowel, and 57% were independent from memory. Even for those whose trajectory path didn't look great, who didn't leave rehab, maybe out of PTA or following any commands, making real FIM scores, at 10 years, they were doing phenomenally well. Just because the slope of that curve is low doesn't mean that it's not upward. These patients really do do well. I think that you've got to think about being patient with these patients, taking some time and allowing them to develop, because they really do have potential. We haven't been able to fully wrap our heads around that. The data probably doesn't delineate exactly who and when and what the course is going to look like for each patient. The fact is that they do have potential. I think you've got to have a high index of suspicion for the potential that the individuals do have. On that note, I think we will transition into our case study. While I'm setting that up, if Dr. O'Brien or Dr. Rosenbaum wants to answer the question about the GOAT versus the OLOG versus the West River, Westmead. Go ahead, Amy. I'm curious what your take is too, though. I said the Westmead is good too. I think that there's a number of options, but if your patient has a traumatic brain injury, for me personally, I use the confusion assessment protocol, which includes the GOAT, which can be substituted with the OLOG, as well as other measures of post-traumatic confusional state like attention, reasoning, and some qualifying measures on sleep and presence of psychotic symptoms. The Westmead is fine as a substitute for the GOAT. I just feel like a lot of TBI research uses the GOAT, and maybe that's just preference. The caveat being the Westmead is specific to memory and not necessarily some of the other cognitive functions that get impacted in confusional states. From my standpoint, while this sounds interesting coming from someone out of Houston, we frequently use the OLOG, or at least I do, instead of the GOAT. It's been shown to have less subjectivity in terms of inter-rater reliability when administering and following that. With respect to the confusion assessment protocol, the CAP, I find, and we have found that it's much more difficult. It's not as quick and dirty as the GOAT and the OLOG. We have not used the CAP. While that is the recommended assessment following to look at post-traumatic confusional state, we have not done that, but usually track with the OLOG-COGLOG. I guess the main point there, which is really important because I don't know what settings everyone is in, but the key is it depends on your setting. If you need something that is really quick, then the OLOG or the GOAT is great. I agree personally that the OLOG is better because it also allows for the queuing, so you could get a real better sense as to whether it's confusion versus language or some other difficulties that are impacting their recall. There's that advantage too, even though that's just my informal opinion, not research-based, but I happen to be in a setting where we have a little bit more luxury of time, so the CAP does take probably more like 15 minutes to assess in its entirety. All right, do we want to head into the case study? All right, so our first question, are you familiar with the DOC guide? We have 30% not familiar at all, 50% somewhat, and 20% very. Next question, I guess, do you implement the DOC guidelines in your practice? While we're waiting, can you all share what sort of setting you all are working in right now in the chat box, just so we're kind of more informed of who our audience is? Maybe just drop a line or two about where you work. Yeah, between the two nights, we're going to utilize the same case study, but again, not knowing what setting or level of the continuum that you are practicing. We wanted to follow a case from acute care through post-acute and attempt to demonstrate application of the guidelines and the minimal competency recommendations at the various levels of continuum of care, so that hopefully we can make this applicable to any area in which you practice. Oh, I'm seeing a couple pediatric hospitals. So I was going to say, there's a fair amount of pediatrics here, which is nice. So interesting, while we're waiting for Brian to bring that up, in terms of pediatrics, the guidelines do have a few pediatric recommendations, but the current consensus is that we really just treat them very similar to the adults when it comes to assessment of consciousness and treatment there, whereas everything else obviously would be pediatric PM&R and pediatrician treating them. We did recently start seeing more of them at our facility at TIER, and we invited our pediatric team to join our DOC team so that we can give those patients the best possible care. So it's been a learning process for all of us, having both a pediatric PM&R, our DOC PM&R, our pediatrician, and having all of those on the team at once has been really cool to learn from. So it looks like we got the question up, so we'll persist forward. All right, so the second one, do you implement the DOC guideline? Okay, well hopefully this means the people who know about the guidelines are using them, because that seems to be a higher percentage than the level of familiarity. I hate that word. And I assume that not at all is the large portion of people who didn't even know about them. Looks like, I mean, we kind of cover the gamut. You have peds and adults, a lot of inpatient hospital, but then at least one outpatient, and at least one who pretty much covers the gamut of acute to long-term care. So it'll be interesting, because we hopefully have some input from across the continuum here. All righty, so our case study for tonight, we're going to name this random gentleman Michael Sutton. He's a 26-year-old Caucasian gentleman, right-hand dominant. He was a graduate student studying engineering, not married, living in a second-floor apartment. His support system includes his mother, his stepdad, his sister. Hobbies are unclear, but seems like he enjoys driving too fast and trying illicit substances, a POA or Guardian. He was involved in a high-velocity motor vehicle accident. He was a restrained single-occupant driver. There was a positive loss of consciousness, of course, and his initial GCS, or the first one that was reported, was 3T, of course. He arrives in the emergency room, and the trauma-slash-emergency medicine team documents that GCS is, of course, 3T. They do document bilateral dilated pupils with slow papillary responses. Brainstem reflexes are clearly present. The toxicology report, again, is positive for THC and alcohol, kind of like a patient anybody out there knows. The emergency medicine physician surprisingly recommends a CAT scan of the head. What do you expect it to demonstrate? If you want to chime in, please unmute yourself or write it in the comments. I'd love to hear what everybody's thinking. Yes, I believe, and Brian, correct us, but you do have control of your mute function in this event where you can come on and either verbally give your answers or thoughts, or if you're shy, go ahead and put them in the chat. Correct. At the bottom of the screen, you can unmute yourself and bring yourself on camera. Not the most courageous group in front of us, I guess. All right, you seem to like the polls better, so let's try it that way. If you're not courageous enough to type or to talk, at least click away and let us know what you expect on this CT of his head. What was found was hemorrhagic contusions to the frontal and occipital lobes, severe cerebral edema, and multiple areas intraparenchymal hemorrhage near the corpus callosum in the great white junction, making the fourth answer correct. All right, and this is a typical example of diffuse axonal injury, which is what we're talking about here. It's small petechial hemorrhages, again at the great white junction, due in part to the centripetal injury as well as the shearing forces that occur during high-velocity injury, consistent with disorders of consciousness. So the reason that you expect these things is that while there may be some contusional injury, those are usually not enough to cause disorders of consciousness. You have to really break down some of the deeper connections, especially those connecting the cortex, the reticular activating system. Without those deeper kind of injuries that occur with high-velocity injury, you really don't have the correct setup for disorders of consciousness, and you're probably dealing with a different etiology. So understanding that underlying pathophysiology is just really important so you know what you're looking at. And just to add to what Dr. DiTomaso is saying, you will be surprised at how many referrals you will get of this patient with a disorder of consciousness, and they have a large left MCA stroke. And what we know from pathophysiology is a unilateral stroke should not take out your consciousness awareness and arousal system. So that is your number one cue that you're not looking at a disorder of consciousness. You might be looking at sedation from medications. You might be looking at an aphasia, but you're not looking at a disorder of consciousness. So I know when I say it, it sounds very obvious, but you will be surprised at how frequently you will see it. Yes, agreed. All right, so question number six. Based on what we've told you so far, are you comfortable giving a prognostication for this gentleman? We'll go back to the case slide. The essence is that this is a high-velocity motor vehicle accident. You have some pupil reactivity. You have present brainstem reflexes. No one thought he had a poor prognostication. That's interesting. That's why we love the psychiatrist. Right, exactly. All right, so let's update Mr. Sutton's condition. So he's still in the ICU, of course. Sedation is removed, and there are no obvious signs of consciousness. EEG shows what you expect. The patient is able to execute spontaneous breaths, and the trauma team indicates that there's a poor prognosis for meaningful recovery. They recommend transition to hospice care. Go to question seven. Given what I've told you now, do you have different thoughts on the prognostication? Moving now towards fair prognostication. Sure. Can I ask, for those who provided or switched from a good prognosis to fair, what about the information that you received changed your mind from good outcome to fair? Five days going by and still no obvious signs of consciousness. So some time has elapsed, which makes you a little less positive. Thank you for sharing that. Anyone else want to share? All right, move forward then. So if that's the case, if you're moving towards fair, if you were the trauma team, what is it that you would offer the patient at this time? What would you recommend if you were a physician on the case and the family asked you? Sorry, just before we move off of the prognosis piece, we didn't really get a chance to cover the indicators of a good or bad prognosis as far as behaviorally. And so I just wanna cover off on that quickly. So five days is definitely, every day that goes by that the patient is in deep coma is you get a little bit more cautious early on. But the challenge I think at the very early level with prognostication in general is that the signs that indicate whether the patient's gonna have a good outcome don't necessarily emerge until possibly months later. Like a patient can wake up, not from deep coma, as we talked about earlier, the longer they're in deep coma, even the chance of survival goes down. But you could be in a vegetative state until four months post-injury and still have a good outcome. And so I feel like it's just one of these challenges that we face because we have to make some prognostic judgments early on, when the reality is we really don't have any information at that early stage to be able to make an accurate prognosis and that even communicating that level of uncertainty to families is important and can make a difference because we feel compelled to answer family's questions with a certain level of confidence so that the family has confidence in us. But the unfortunate reality is that we just don't know because then for those of us who see that much data later down the line and the family's holding onto the fact that they were told their loved one would never recover or vice versa, they were given a blanket statement that they'll do well. And so just adding that caveat, especially when interacting with families, I just wanted to. And to add on that quickly, and that's something that, again, there's just not enough time to cover some of these nuances, especially of acute care of severe brain injury and the decisions that have to be made, not have to be made, but the paradigm of care, that's the thought. And I cannot remember, is it Turgeon's study, but 70% of brain injury deaths is not because of the severity of injury and they just could not keep the patient stabilized and the patient just naturally expires because of the severity of the injury. 70% of brain injury deaths are because of the counseling and decision to withdraw care. Where if you look at this, so it's a self-fulfilling prophecy, this nihilistic prognosis, and that 68% of that is usually occurring in the first three days of injury. So we're not even beginning to get a feel or rule out the confounds that Dr. Rosenbaum discussed and Dr. DiTomaso to even get down the road to see, okay, is the brain starting to fire up? Are we starting to see some upregulation? We're just not even giving them a chance. And that's another area of care and knowledge translation and dissemination to try and change that practice that we see across the country because historically there's just been this nihilistic prognosis of like the MRI looks bad if they even get an MRI at that stage, CT looks bad, there's not a lot of activity going on with the EEG, this is gonna be a poor prognosis. And really in those early days, we can't say it with any type of certainty. And maybe I probably overspoke of our questions, but I had to get that in there. No, you're absolutely right. Inadequate with detergent study, it definitely was eye-opening about how often withdrawal of care is occurring before people even have a chance. The other thing I'd like to point out is nobody consulted palliative care. And while palliative and hospice in many places are quite overlapped, I don't think it's ever wrong to consult palliative care. They oftentimes can come in and address some of the needs that the other teams haven't, especially if PM&R hasn't been there and hasn't been active. Other places, it's just a conduit to hospice. So in those cases, I agree, it would not be very helpful knowing if you have that service and if they have a distinct role, could be an option as well, of course. And maybe I jumped the gun a little bit on that portion of the discussion. I just didn't wanna jump over the prognosis piece, but it looks like the overwhelming majority of the audience, whether because they would have picked that anyway, or because of our emphatic speeches, they picked continual aggressive care, so. We're physiatrists, we're gonna take rehab every time. All right, so there was an AAN ACRM guideline that was violated. So did you notice, did you pick it up? We've kind of given it away a little bit. See if you can read through those options and pick the one that the trauma team violated, and I'll put up the poll questions so you can vote. Most people got it. The AAN ACRM guidelines recommend never giving a universally poor, not that you can't discuss poor prognosis, but keeping a light of hope for at least 28 days, which clearly was not done in this case. So this is very timely. In terms of talking about prognosis, here in Houston, we use the hurricane analogy that many have published about in the literature, knowing that from the time a hurricane forms out in the Atlantic or in the Gulf, your cone of uncertainty is very large. So out in the Atlantic, that hurricane can hit anywhere from Dr. Rosenbaum up in New York to our friends down South in Mexico, and so that cone of uncertainty is very large, and the same goes with the prognosis after brain injury. Day one, we don't know if the person will survive or have a fantastic recovery, so your cone of uncertainty is large. The further you get from the time of injury, the more narrow your cone of uncertainty becomes, and therefore you can predict and prognosticate better what this person's future would look like. What's important is CT scans, imaging, it doesn't matter how advanced it is, it does not predict outcomes. So we have seen people who are having fantastic recoveries who I wonder what connections are left in there when I look at their scans, and other brains that look very normal that can't figure out why I can't find consciousness on someone. So the idea that we have all this advanced technology doesn't necessarily give us any better prediction early on in the course of recovery. So whenever anyone asks, you say you don't know until you're further away, and we often give that hurricane analogy. So it's really important, and I'm, again, preaching to the choir, you're in rehab, you know what you want for these patients, it's helping our acute care colleagues understand their job saving the life, our job giving them the life. So it's really important to avoid those prognostic statements and being comfortable and certain with the uncertainty and sharing that with them. All right, so we talked a little bit about the different consultations and what comes next, and I think this slide was to prompt us to talk about the fact that really we can set what we think is happening with the patient, but you've got to stop and talk to the patient and the family at this point, figure out what it is they want for the patient, right? And in acute care, it can be very difficult because they're in such a state of shock and crisis mode, and you may have had the same conversation with them and your team multiple times, and they're asking you the same questions, and that's to be expected. I always think DOC families need a lot of TLC, acronyms, abbreviations, but because it's just such a strange and difficult phenomenon to understand, like the person's alive, but yet they're not here, and when will they wake up? And there's so much anxiety around it and so much unknown, and just as we're discussing here, we don't know the answers, and they're looking for us for that prognosis and crystal ball of, when are they going to wake up? Are they going to start talking? Are they going to be able to go back to what they were doing before? Are they going to be normal? And we don't have the answers to any of that, especially in the acute care phase. So it's really pertinent to sit down and have those conversations and explain to them and try and provide as much simple, direct education as you can of what their loved one's experiencing and what their options are at that point. Having the prognostic humility of, we don't know how this is going to turn out. The only thing, just as Dr. O'Brien was saying, we won't know more until we get further out from the date of injury. And so right now we don't know, but here are the options of further care, but here are also the options of potential outcomes. And the possibility of those potential outcomes and which way it's going to go isn't going to become more clear until we get further down the road and do those specific assessments, serial assessments, implement some of those guideline and minimal competency recommendations to start narrowing the focus and increasing the confidence of what that long-term recovery trajectory is going to look like. Any questions or concerns on that? Dr. O'Brien or Dr. Rosenbaum, anything to add? No, I think Brooke summed it up perfectly. I think the only other piece is really to use the resources you have around you to help inform the care plan. So beyond prognosis, you may be more in a position to be guiding what their service plan should look like and whether or not they should go to rehab versus a skilled nursing facility. And really this is where it sort of shifts into if you have not already become familiar with, it would make sense to refer to the minimal competency recommendations as well because it's not, even if you're not the person creating the program, the idea is it really spells out what is a specialized rehab program and what the intervention should look like and the medical management piece should look like. And so really, I think, especially since you all are recommending a continued aggressive care, and maybe we're still too early, post his recovery here to be talking about transition to rehab, but it's just the thinking of readiness for rehab in these cases from day one. And that's probably natural in your mindset already to do that. But for these patients, it may involve calling it a little bit more recruits. In other words, referring to PT, for a PT, OT and speech assessment, whereas you might not necessarily be thinking to do that right off the bat. Maybe you're thinking more about their comfort positioning and calling them in for that aspect of their care, but it may not be the neurologist or the primary care doctor who's asking for the assessment to be done. So we kind of rely on you, our physiatry friends, to be the one to have the understanding to say, should we evaluate, administer the CRS or recommend speech therapy or whoever it would be to do that so that we can start collecting that objective data from day one and identify more of those medical management issues early on that need to be addressed to help make them more appropriate candidates when they're stable. Great segue for our next slide. So on day 11, the family requests the rest of treatment as most of you recommended. So thoughts in your head, does he get a trach and a peg? Should we extubate and see how he does? We know that he's able to open his eyes now spontaneously during the day. The eye opening has no obvious trigger, so he does it voluntarily, we suppose. The eye opening continues for minutes at a time, and that's where PMNR gets in. All right, so we're all, or most of us at least on this, are physiatrists. Dr. Weintraub was eager to pick your minds on what you think a DOC evaluation should include. I'll encourage you if you're able to chime in or write in the comments what you think are important elements of the disorder of consciousness evaluation by the PMNR physician, and we'll see if it matches with Dr. Weintraub, formerly of Craig Rehab Hospital in Denver, Colorado, if that was appropriate. No poll on this one. Just shout it out or type it up. Since you're waiting, I don't know. I'll try to answer the question and hopefully other people can chime in. And you said Dr. Weintraub formerly of Craig. Is he no longer there? I think it's knowledge. I hope I'm not blowing his cover, but he has semi-retired. Oh, good for him. I've known Alan for a long time. I think that, an evaluation would include many of the things that you've already talked about, but ideally, I think PMNR would have been involved before day 11, first of all, in a well-thought-out trauma program. But you would start off with getting an understanding of who this patient was before, what their level of function was, any pre-existing comorbidities, and then looking at the things that you've already talked about the medications that they're on, medications that might be impairing level of consciousness. And you've already mentioned that. And then, I think that you would like to see a PMNR doctor do a comprehensive evaluation and include it all, not to be repetitive to what you've already talked about, but to look at the things that you've already talked about. And then, I think that you would like to see not to be repetitive to what you've already talked about, but at least at a certain point in time, what their level of consciousness is, looking at the cranial nerves that you talked about, addressing any other comorbidities that are there, looking at the potential of loss or range of motion, skin problems, contractures, those types of things, what the nursing care has been like, and what the nursing plan of care is like, and what they're doing to prevent the complications you see for these kinds of patients that can impair their recovery as they go further. And then, sitting down and trying to get a good understanding of what it is that will be available to the person in terms of family support, insurance, possibilities as far as next level of care, and then sit down and talk to the families about educating them on what's happening and what potentially comes from here. So, I'll stop there, but at least that's a starting point. All right, that was really excellent. Thank you. And a lot of really excellent things have been mentioned in the comments as well, so I advise you to look at it. Dr. Weintraub broke it down this way, and I'm certainly no substitute for him, but I'll do my best. First off, he felt like there had to be a thorough medical evaluation. We had to understand, as was just mentioned, the medical issues and the things that were going on from that standpoint, as well as what the medical exam looked like. A thorough review of the medications was absolutely essential, and then a physical examination, as has been mentioned by many people. He thought the diagnostics both needed reviewed as well as suggested, when appropriate, for further evaluation and workup. And then he wanted us to really talk about team building. As I think Dr. Rosenbaum so intelligently pointed out, you've got to get the right players on board. Do you need an ENT to look at the throat and the swallow and the trach? Are those things going well if they're already there? Do you need a neurologist to come in and look for seizures? Do you need different team members to get on board and start to set this patient up for success? And then lastly, as you just mentioned, Dr. Desjardins, to begin setting some goals with the team as well as the family about where we're going next, how we're building this, what we're looking to get through and establish. So I think if you're unfamiliar with doing this, if you're interested in getting more involved, this is a good kind of outline for you to start with. And I appreciate Dr. Weintraub giving this. And I agree with all of the comments and everything he's just said as well. All right, so what do we see in our PMNR evaluation? The patient now is clearly opening his eyes spontaneously. We are unable to characterize any ability to track. He is breathing on his own. However, he still has frequent desaturations noted, and we do not detect any volitional movement during our examination. Okay, so you're visualizing this patient in your head? Good, I'm about to throw a question at you. What level of consciousness do you feel this patient has? You're muted, Amy. Craig, you want to just move back the other slide while they think about this so they can see the behaviors that are present? Sure. I apologize, we don't have a poll question for this particular one. So you're again going to have to either shout it out or write it in the comments that someone has already done. We have one unresponsive wakeful syndrome. I don't know how many. Does anyone disagree with that? Throw it out there and speak now or forever hold your peace. There's another response back to the other question. The UTI. Well, I would agree with the UWS diagnosis. How about you, Dr. O'Brien? I think with the information we have, we could say that there is no behavioral evidence of consciousness there yet. However, again, we're still very early in the course of it. So if I were speaking to a family or talking to my colleagues, you know that absence of evidence is not evidence of absence. So at this time, I don't have evidence of consciousness, but that does not mean the patient is unconscious. So you all got, you were correct in the sense of calling it UWS because we don't have anything on this case that says otherwise. However, it's still early to tell. So even if I were part of the initial PM&R evaluation and I had gone in and done my record review, done my chart review, evaluated the patient, I typically would not conclude a level of consciousness off of that evaluation. I would talk about what I saw, what I'm looking for, speak to the family, but not make any kind of diagnostic statement to the family until I have seen the patient on multiple occasions. As Dr. Rosenbaum said earlier, you want multiple assessments over multiple times. Typically, you know, when we're called for consult, they're usually just moved. My favorite is when they call you right after they place the peg and they're still under anesthesia or, you know, and when I get those records, I'm always like, well, of course they looked unconscious. They were under anesthesia still. But so yes, you all are correct, but I also want to point that it's still too early to say. Yeah, and I'd like to add to that, emphasizing that those behaviors are characteristic of vegetative state, but in this particular case, you'd also want to know how, if you saw the diagnosis of unresponsive wakeful state, you'd want to know what that diagnosis was based on, right? Because especially in the ICU level of care, it's not really common to request CRSs. And Dr. O'Brien, I don't know if you do consults in the ICU or if you could speak to, you know, whether that is really a common thing from that respect, but I know that there are efforts underway right now to try to create a ICU-based version of the CRS because the CRS could take like a half an hour and there's just a lot of logistical and, you know, practical reasons why that's not reasonable. But again, you would suspect the vegetative state, but I wouldn't even rule out the possibility that the patient might behaviorally be able to demonstrate something higher. I'm curious, you know, how those cognitive, how higher level cognitive abilities were assessed. And if the patient has a right, I don't remember if he had a gaze deviation or if we commented on that, but he could be cortically blind. So him not appearing to track is irrelevant if he's cortically blind. So we'd want to make sure that there was a somewhat formal assessment, even if it was a modified version of the CRS, but still at least following the general sense of it before making a formal conclusion. Yes, so I am not personally doing them. And I will say we have our PM&R acute care consultant, Dr. Ryan Stork here in Houston, who goes over to the acute care hospital and sees all of these. And no, I don't expect any of my PM&R colleagues to do a formal CRSR on these acute care referrals because one, I don't, I mean, the way our system is set up at this time, it's just not feasible, but I'm hopeful that the tools coming out in the future will assist in that. But we do have acute care, physical therapists, speech therapists, occupational therapists who have been trained in the assessment. So when they're going in, rather than just doing passive range of motion or sitting someone in a neuro chair, they are doing far more than a lot of the acute care therapists in many settings because our rehab has gone over and trained them in that and taught them these guidelines. And so we're trying to make that big impact because we can do everything in our power at our level of care, but if we are not getting them to us, it's not gonna help us. And that's where a lot of the initiatives have been with PM&R and kind of acute care and trauma surgeons really coming together in the evaluation of these patients. And with that, I'll let you keep going because I'm excited with this discussion. I don't wanna run out of time. Yeah. It looks like some people are actually already in the habit of asking speech therapy from referring facilities to assist with CRSs and therapists do them PTOT speech are all trained. So, I mean, which makes sense. We're obviously speaking to an audience that has some interest in this population for some reason. I think part of the challenge is sort of expanding the skill level beyond the people who already have some level of expertise to other centers or staff who wouldn't necessarily have the training but are seeing these patients anyway, like the people who are receiving them in the skilled nursing facilities and those other post-acute settings. Yeah, I mean, those commenting that they're therapists, especially if they're in acute care are trained in the CRSR, in my experience with the trauma systems that I consult with, that's an anomaly. And so, one, that's great and exciting, but two, if you're not sure, those are some questions to be asking. If you're a PMNR physician consulting in acute care and you're wanting or needing some of this behavioral bedside assessment information, be asking those questions because don't assume that your PTs, OTs and speech therapists automatically know how to complete this assessment and complete it accurately where you can feel confident in the results. Because again, unfortunately, this isn't training, speaking from an OT who's been out almost 20 years that we come out with any of this information. So if you are not getting this in your clinical rotations or on the job training, as it looks like a lot of these therapists are and that are related and working with these physicians on tonight, be asking those questions and be pushing for that education and training because it's so key, especially to get them access to the next level of care if that's what the family is wanting to do or that's even the recommendation of the team because I won't go any further. I don't want to spoil things. I'm trying not to get on my soapbox. All right. So catapulting forward from Brooke's last comment for the physiatrist out there, what are you thinking about for confounds of consciousness or what can we do to perhaps help this patient move forward in that level of consciousness? In the interest of time, maybe we'll just spend a few seconds letting y'all think about that. Someone wants to talk about it, please engage. I do think somebody in response to the earlier question had, this may not necessarily have been directly for this answer, but somebody in an earlier comment spoke to evaluation of sleep-wake cycles. So I'm just going to throw that out there assuming that that thinking behind that was that that might be a confound. Yeah, I think that's a great confound and one that not everybody thinks about. We'll go into that in more detail on part two next week. 30 seconds for everybody to think about that. So we're going to jump into medication management with that thought. So running the MAR of this patient, of course I've boiled it down to a relatively short list so that you have a chance to digest everything. We all know that these patients, unfortunately are often on multiple medications. Is there something here that would worry you? Is there something that you would want to wean? And we'll open it up as a poll question as soon as I can drive this properly. So if you're out there reading this and thinking about our patient, Michael Sutton in front of you as the PM&R consultant, is there something here that you might be interested in stopping, weaning or adjusting? Yes. How far out post-injury are we? Dr. Timotasi? I think we had said 11 days on the last slide. There's some clinical information perhaps that will help guide you. I guess we said we got the PM&R consultant on day 11. So being good physiatrists, we'll assume it's no later than day 12 because I always get to my consults within a day, right? We have a few different thoughts here in the chat. I'll pull there and let everybody take a look at what you're seeing. And I'll go forward. I thought the right answer here was levotiracetamonazate. He's out of sight of the window for antiepileptics. We have an EEG that did not indicate that there's any seizure activity. Everything that was reported previously is pretty appropriate for someone with a severe traumatic brain injury. While I know scopolamine is tempting, as I mentioned, it certainly is sedating. The issue, of course, is this gentleman continues to be desaturating. Scopolamine sometimes does help with respiratory secretion management. There's never one perfect answer in these patients. So I wouldn't impose upon you that it was absolutely wrong to wean anything else. I just think that given the timeframe and the scenarios we've set it up, levotiracetam, at least to me, is a little bit of a better answer. Hopefully those five people are stirred up and we'll come back with some forceful questions. There is some also comments about the importance of ruling out medical complications over medication as a first step. So what do you think with respect to that? Is it not matter necessarily the order? Should people be thinking about a stepwise process where you do prioritize medication versus complications as a first line of thinking? You know, I think that's very reasonable given that we've already had one negative EEG. I don't see that we have to repeat it. Although I don't think there's anything wrong with doing that either. Of course, this gentleman obviously is at very high risk for epilepsy. So I think you could go either way. We have some guidelines and some evidence on when to wean the levotiracetam. So to me, that just comes first. That means much more of a gut feel. So I guess you would have to depend on how much you think these desaturations are related to problems with secretions versus possibly other etiology. So probably no one perfect answer, but hopefully I've got you thinking a little bit about that. No one seems to want to argue tonight. Perhaps it's getting too late for everybody. I do think also in terms of ruling out medical complications over medication, we all, to my knowledge, are in the United States and are functioning under our current healthcare system. And therefore we don't have a perfect system. So I know Amy was able to say earlier, she can keep a patient from up to three months to a year. The majority of us in inpatient rehabilitation don't have the luxury of that sort of time. And therefore, in terms of attempting to make good decisions for our patients with medications and interventions, we do have to think a little bit because we can't really wait to see the effect of one before starting the next intervention. So it's really just being very, what's the word? I kind of thoughtful in your process, but I don't think there is any one right answer. I think it's going to be different for each patient, but the thoughtfulness is the part that's most important, I would say, given our system of care. Yeah, perfectly well said. Don't know that I could follow up. And I would just add though to say, I think that the part of what we're trying to drive home is what Dr. DiTomaso said about, if there's a guideline for it, if there's evidence for it, that should serve as sort of a directing, I can't think of the right word, but that sort of has a little bit more weight because there's not many things that we do have evidence for in treating these patients. And if there is something and you're juggling, then going with the evidence-based approach or decision, you're never going to go wrong. It's not like you're not going to circle back and address those other issues, but use the guidelines and the evidence as your guide is the main message. I guess just one last point, just to make sure I'm covering all my bases. Someone did mention that there were spikes on a previous EEG. And if you remember, and I know it's a very subtle point, I don't mean to belabor it, but if spikes in the acute care typically are not a bad thing, that's a normal part of the brain injury healing. If those spikes are still there two, three weeks later when they get to rehab, that's when it becomes problematic. So that would not deter me from weaning the Levitz-Gray system. All right. But again, I don't think the right answer is as important as being thoughtful as both Dr. O'Brien and Dr. Rosenberg. All right, so now our money question for the physiatrist in the room. What do you write as your disposition recommendation? We'll launch that poll. All right, so who wants to take this one? We've been dreaming of responding to this poll since we started writing this question. But I think we maybe failed to take into account what you said earlier today, but we're talking to largely a group of physiatrists who understand the importance of rehab. So we are preaching to the choir to some extent. But I am happy to see that the majority of people would, and that the overwhelming majority of the people that didn't sent him to an LTAC, not necessarily recommending no care at all. So, yeah, this is appropriate and ideally what we would want to see to get these patients access to rehab because that is guideline recommendation number one in the paper. However, make sure everybody on your team, and we'll talk about that interdisciplinary collaboration next week, is on the same page. Because it's one thing to recommend the next level of care, it's another thing to get them there, especially as Dr. O'Brien was alluding to our health system. So if you recommend inpatient rehab, but then somebody else on your team documents or puts in the EMR, not appropriate for rehab, can't participate, yada, yada, yada, somebody is going to look at that and go, oh, going to deny going to rehab because right here it says not appropriate for rehab. So again, another emphasis on everybody communicating, getting on the same page, knowing what's happening with the assessments and what is being recommended and why. So that there's congruency with the documentation and advocacy to all the parties and stakeholders involved to be able to get them to that next level of care that you as the professional are recommending. And I think that also it's kind of challenging because I think the holistic, and this is sort of going a little bit more into the minimal competency recommendations and a little outside of what we specifically spoke about but ultimately number one is that regardless of the care setting, so you could potentially have an appropriate SNF setting if that setting had a specialty DOC program. So I think there's a couple of messages here, at least from my personal experience, even all inpatient rehabs are not created equal, even all TBI rehabs, specialty rehabs, even the model systems, not created equal for these patients. So I had a patient, she wasn't even a patient, she was a potential patient from Pennsylvania, I live in New York. She was denied and I see there's a lot of talk about the insurance and the chat and absolutely, obviously that's part of the issue is the bigger access problem from insurance and the broader system of care. But anyway, she was denied into any rehab in state and the family was trying to get her approved to go to out of state, trying to prove that they didn't have the programs available in her state. But she was referred to two big TBI model systems, acute rehabs elsewhere in the country, very reputable facilities and she was not accepted for the reasons that we're sort of alluding to. She was deemed not able to quote unquote, tolerate three hours of therapy and quote unquote, not able to actively participate. But the thing is she was a TBI, she was young, otherwise healthy, she was not even a month post, she was not technically prolonged DOC yet and she was already beginning to communicate. So she was actually on the upper end of MCS and they came to find my program because I am technically located in a SNF, but I'm a subacute rehab and as we heard, it's a specialty program and it has special staffing and was created for these types of patients. And so that would have actually been the best environment for her because acute rehab is really structured for patients to be in and out within six to eight weeks. Many of them are geared towards the higher level patients with goals of ambulation, safety, balance. So even the specialty TBI programs don't necessarily have the expertise to treat this particular population. So I think in being fair, it's less about which is the correct to some extent and first and foremost important that you have the right players with the right expertise and the right multidisciplinary team members available so that they can get the services that they need. That said, ideally what we're talking about is what we all think of as an inpatient rehab program, the multidisciplinary team with the access to the consults and all of that. So that sort of is my soapbox. We only have two minutes left. Apologize, Dr. Rosenbaum, to cut you off a little bit, but we've got to get everybody out of here on time. I think that's reasonable. Would like to say much to your point though, the number one guideline is a recommendation to a multidisciplinary team, not particularly inpatient rehab, SNF, or LTCH. Two of my three DOC programs have been housed in LTCH. So you can definitely get it done with different resources if built properly. So that concludes our first night. I hope everyone enjoyed it. We will certainly take your feedback if you have some, because we are interested in making night two the best that we can get. Feel free to use the comment box for the next two minutes, or I'm easy to find on Twitter. Email any of the applicants if you'd like, give feedback directly to the AAPMNR, and we look forward to seeing everybody next Tuesday. We will again have approximately two hours of lecture and an hour to continue Mr. Sutton's journey and elaborate rehabilitation caveats.

disorders of consciousness

evidence-based guidelines

assessing

treating

accurate diagnosis

specialized care

levels of consciousness

criteria

conditions

assessment process

sensory functioning

motor functioning

prognosis

rehabilitation

interdisciplinary collaboration