Welcome. My name is Alan Weintraub from Colorado, the Rocky Mountain Regional Brain Injury System, and I am absolutely thrilled that Dr. DiTomaso, Murtaugh, and O'Brien have put together this seminar today. This is a follow-up to two previous four-hour spotlight seminars on this topic. I will introduce these presenters who are going to utilize an interactive format around a case on this topic often challenging to practitioners like yourself related to severe traumatic brain injury or non-traumatic acquired brain injuries that lead to syndromes or disorders of consciousness. You know, all too often, I will be rounding with a resident, usually a resident, not a brain injury medicine fellow, and I'll say, let's examine this patient together and please explain your findings, and I have more than once heard the response, I cannot examine this patient. I said, well, what about a basic neurological examination from head to toe? And often a resident in their training in PM&R are somewhat stumped by this question because these patients have such a profound presentation related to their injury and their impaired consciousness that often a resident in training doesn't know where to begin. This presentation is going to highlight the importance of an extensive neurological examination but a much more quantitative, granular way of looking at these patients, which is essential to understanding what type of prognosis and recovery pattern and management they're going to need. Second, you'll often be in an interdisciplinary format with a physiatrist or perhaps even traumatologist and the team, and you'll talk to therapists about how they approach and manage a patient with severely impaired consciousness following their injury, and you'll get a response of, I'm really not sure this patient doesn't interact with me, and it becomes your or our job to work through how you approach these patients clinically with such impaired consciousness who often needs more issues done with them and to them than they're able to participate back. And lastly, and one of the biggest concerns, and I'm hoping we can enter into the chat room for a Q&A on this, is you will see a patient who might be days or several weeks post-injury with a profound disorder of consciousness in an ICU setting, and we will hear that this patient cannot participate in rehabilitation and therefore cannot be admitted to our inpatient rehabilitation program, which is sort of a bewildering concept when you think about the severity of their trauma, what we know now about prognosis, recovery patterns and outcomes in patients who are even in this state one month post-injury, and how we can be most beneficial to this patient population as they enter and build a foundation for needing to be involved in a system of care and dealing with their new life. This presentation is going to give you a 360 degree or a bird's eye view, if you will, by looking at a case on how to best approach and evaluate and manage these patients with severe injuries with impaired consciousness in the context of published best practice guidelines. I'd like to introduce to you colleagues and experts in the field who have hands-on knowledge of managing many of these patients, Drs. Murtaugh from Madonna Rehabilitation Center in Nebraska, Drs. Katie O'Brien from Teer in Texas, and Dr. Craig D. Tommaso who has an appointment in Texas at Baylor and Teer and is the medical director of post-acute medical and U.S. physiatry. This is our team. I'd like to welcome them. Dr. D. Tommaso, can you take it from here? Thank you for the introduction, Dr. Weintraub. That was quite flattering. I'll actually turn it over next after you have a chance to review the objectives and the disclosures for our team to Dr. Brooke Murtaugh who will take us through the genesis of the Disorders of Consciousness Guidelines. Thank you, Dr. Weintraub and Dr. D. Tommaso. I am going to start us off and do a quick overview if you're not familiar with the Disorders of Consciousness Practice Guidelines that were published in 2018 by Dr. Giacino and his team to really outline evidence-based recommendations of how we should be approaching patients with prolonged disorders of consciousness. So to kind of set us in the right context of how we're thinking about these patients, where we started, where we're going, as we work through the case that will be presented over the next hour, this is going to kind of give an intro so that you know why are we applying these guidelines to a case and why do we want to be aware of them and really focus in our practice on implementing these guidelines because they really are the first evidence-based tool that we have that can outline where we start and what we need to be doing with these patients. Not only in acute care, but then as that patient hopefully gets the opportunity to move on through post-acute care. So quick history, just a snapshot, you know, how did we get here in 2021 with the DOC Guidelines? Back in 1959, we had the term Coma Vigil and Plano and Posner's diagnosis of stupor and coma published in the 1960s and again in 1982 where, you know, we're starting to define coma and vegetative state, you know, identifying the phenotype of these patients, starting to identify the endotype and why they look like that. And so that led us to that vegetative state clinical definition by Jeanette and Plum in Lancet in the 70s. And so we kind of had a term for a syndrome that, you know, initially and for decades, centuries didn't have a name. And then everything kind of just held steady there until Dr. Giacino and his Aspen Working Group published the clinical definition of the minimally conscious state, really identifying that, you know, there is this phenomenon and this behavioral presentation of a patient with severe brain injury that doesn't meet the criteria for vegetative state, but they're not fully emerged into consciousness either. And this is how this definition came to be in 2002. Two years later, Dr. Giacino, Kathy Kalmar, and John White developed and published the coma recovery scale, which Dr. O'Brien will talk about later as we present the case. But this really is the gold standard of behavioral assessment for these DOC patients. So it looks at different domains of behavioral function and really outlines, you know, depending on how that patient scores, it's a standardized assessment. So there's a certain way that we have to go about implementing it with a patient. But psychometrics have been studied. This is the most studied DOC assessment in the literature, and it has the recommendations with the strongest reliability and validity, and the DOC recommendations discuss this. And so the guidelines were a collaboration. It's development and the whole scientific process, meta-analysis of the data was supported by the American Academy of Neurology in partnership with the American Congress of Rehab Medicine and the National Institutes for Disability, Independent Living, and Rehabilitation Research. So three big entities that supported the development of these guidelines. And so through the process that took, I think Joe says, Dr. Giacino, about seven years from inception to publication, through their review process, they developed 18 evidence-based recommendations in five different domains, assessment and diagnosis, prognosis, prognostic counseling, care and treatment for adults, and then care and treatment for pediatrics. And these 18 recommendations focus on prolonged disorders of consciousness. And how prolonged DOC is defined is anyone demonstrating coma, unresponsive wakefulness state, or what was called vegetative state or minimally conscious state, 28 days or greater post-injury. Because we know the prognosis and trajectory of recovery, if they are still in DOC 28 days or longer, is going to look different than somebody who's fully emerged, following commands, communicating within that first 28 days post-injury. The other thing we want to highlight that we will reference that is an adjunct in addition to the 18 DOC guideline recommendations for practice is the minimal competency recommendations for DOC programs that provide rehabilitation to this patient population. So the process for development was, the bar was a little lower. There's still evidence-based recommendations. There are 21 of them versus 18, but evidence-based and evidence-informed. And these are really helpful to implement in the post-acute care setting. They're very rehabilitation-focused recommendations to help with those post-acute care programs, whether it's LTAC, acute rehab, SNF, to guide what do we do with these patients when the question is what are we supposed to do with these patients? What is considered best practice? And these minimal competency recommendations really help give a framework and a pathway of what we should be doing as direct care clinicians. And that project was supported again by the American Congress of Rehab Medicine in partnership with the Traumatic Brain Injury Model Systems. All right, I'll turn it over to you, Craig. So on that note, we thought that it would be helpful for everyone involved if we worked through it on a case study. For those of you who may have caught us on the spotlight, it's going to look very similar, but that's okay because repetition is the mother of learning. In addition, I see someone's already engaged in the chat room. Please feel free to ask questions as we go in the chat. We'll try and answer as we go as best we can, as we don't know how much time we'll have left at the end. If we do, we'll certainly revisit the questions and explore them more deeply. All right, our case, our pretend patient here is a Mr. Michael Sutton. This is a 26-year-old gentleman, a Caucasian right-handed gentleman who was studying engineering. He was not married. He lived alone on a second-floor apartment, and he had a good support system, his mom, his stepfather, his sister, no real hobbies to speak of, and no POA. Unfortunately, Mr. Sutton was injured in a high-velocity motor vehicle accident. He was a restrained single-occupant driver with positive loss of consciousness. If your state is anything like here in Houston, Texas, 3T is the only GCS we ever see. Bilateral dilated pupils were slow on papillary response per the ER physician. Brainstem reflexes were present, and the toxicology report was positive for alcohol and THC. So, lo and behold, and quite surprisingly, the emergency physician recommended a CT of the head. Our audience participation comes in now. What would you expect to see on a CAT scan of the head? Please put your answers in the chat box. We're not going to shame anybody. This is expected to be a learning session, so if you can give us your thoughts or takes on this, we'd be very interested to see where our audience is coming from. Okay, so here, for those of you who are still waiting to chime in, maybe I can give you some options. Would you expect a left MCA distribution stroke, large bilateral pontine hemorrhages, bicemporal and periventricular enhancement, or small diffuse hemorrhages at the gray-white junction? Okay, and here is a sample image of what Mr. Sutton's CAT scan could very well look like. As you can see, there are hemorrhagic contusions to the frontal and occipital lobes, diffuse cerebral edema, and multiple small areas of intra-parenchymal hemorrhage near the corpus callosum in the gray-white junction. Dr. Weintraub, we'll spend a minute to discuss why these are the appropriate findings and what that means for you as a rehab physician. So, first off, you know, you see what you look for, and you look for what you know, and if you spoke to an acute care traumatologist neurosurgeon on bilaterally, slowly to react, and or fixed pupils, they would report back what they know in neurosurgical literature to carry a very poor prognosis. But you also know that there's going to be some sort of disconnection phenomena related to the Edinger-Westfall nuclei, and you're going to have to have some swelling phenomena that is impacting the midbrain or below. So, typically in a case like this, all I could really think of would be, you know, brain swelling. I'm not sure, but that is not an unlikely MRI what we see, which is a kind of multifocal deep white matter enhancement, a little bit of swelling. You would want to have lower slices to see what the basilar cistern looks like. But this particular CT finding of traumatic axonal injury, formerly called diffuse axonal injury, would be very nonspecific relative to prognosis or outcome. Certainly, this person could have some other multifocal, more specific injuries. It didn't sound like on acute exam, necessarily, that would be specific to the brainstem, because there were intact brainstem reflexes. So, I would have been very surprised to see a pontine lesion. The other, well, I'll just say at this point, it's sensitive and nonspecific for kind of traumatic axonal injury. Okay, moving on. Our gentleman has now made it to day five. The ICU physician removed sedation, and there's no obvious signs of consciousness. An EEG is performed, which is significant for diffuse slowing of brainwaves. He is able to demonstrate spontaneous breaths. The trauma team communicates to the family that there is a poor prognosis for meaningful recovery, and they are recommending transitions to hospice for continued care. Based on the clinical evidence, as we provided you, albeit the limited evidence, what would you estimate this gentleman's outcome or prognostication to be from your experience as a physiatrist? We've listed the Glasgow outcome scale here so that you can more easily reference it, and please put your comments in the chat again. This is a learning environment. No one will be shamed, I promise. So, just one comment. Most everybody in the chat room got what they imagined the CT to find to be correct. There was a comment in the chat room about bifrontal contusions. Mechanistically, when you have a high velocity injury, most likely you're going to see axonal deceleration rotational phenomenon related to deep white matter. Your frontal and temporal surfaces would be more affected by lower velocity and falls, generally 80 to 90% of the time. Now, the patient can still have impaired consciousness, but the depth of that impaired consciousness on examination typically is not as severe as what you presented in this case. All right. And so, based upon the responses, and it looks like people have given good, poor, and fair responses and different GOS scores, so that's fantastic that there's some distribution in the responses. So, what would you consider would be the next options for care? Would you press the family into a DNR? Would you ask them to just wait and see? Would you encourage aggressive care and further rehabilitation? Are you interested in palliative care consult at this time or a hospice intervention? It seems like our audience knows how to read the presenters. Everyone's arguing for aggressive care. I would just add that if you know you have a good palliative care consult, those could overlap, right? Because there are always palliative things we can do to help ease the suffering of the patient. If your palliative care is more a pathway to hospice, then perhaps that's not the right answer. But you have to know your palliative care consult. So in the end, I'll say that all options have some merit. But what does the family want? And I will throw it to Brooke Murtaugh for a quick review of discussing at this point how to approach families and move forward. Yeah. So always, we have the patient in front of us, but there's always a family that comes with them. And family dynamics and what are their care goals? You know, what do they want for their loved one? And so always presenting all the options, but having that prognostic humility. As Dr. Weintraub was saying, you know, we can see the CT scan, but it gives us very little information of what the patient will look like two weeks from now, two months from now, two years from now. And so having that discussion with the family and providing as much education and information about their treatment options, transition options, so that they can make an informed and educated decision. But knowing that, you know, we really don't know at this point, especially in looking at this case. We know it's a severe injury. You know, his presentation at the bedside doesn't look great. But again, long-term prognosis is very unsure, and we have very little level of confidence to say this is going to be, you know, a poor prognosis and the patient isn't going to have any quality of life down the road or make any sort of recovery. Right, and I'll just add there, we discussed what we thought the outcome of this patient would be given the findings presented. And several people talked about fair or poor. And I think the number one thing that we would recommend is that it's too early to make any sort of prognostic statements in that situation, and it should be withheld until more data is collected. So now I'll ask those of you who are maybe a bit more advanced on the Zoom. Which AAN ACRM guideline did the trauma team already violate? Is it one, not using advanced neurodiagnostics to prognosticate? Number two, giving a negative prognostication for a patient with spontaneous breathing? Number three, giving a negative prognostication without an fMRI evaluation? Or number four, avoiding statements of poor prognosis before day 28? Interesting. It seems like we've got, again, another good distribution. Actually, the one that they violated here is number four, avoid statements of universally poor prognosis. That's recommendation number three. Well, it doesn't mean, and this has been misinterpreted by some of my colleagues, that you can't talk about a potentially negative outcome. Of course, you need to have the family aware that it could be negative, but you also need to let them know that 28 days haven't passed. It could also be very, very good. We simply, as Dr. O'Brien said, do not have enough information at this time. So that's really the take-home message. The other scans and imagings were red herrings. If you fell for those, I'd encourage you to go back and look at the guidelines if it's something you're interested in. You really don't need a lot of advanced imaging to prognosticate on these patients. What you do need is some time. And then to follow up with Dr. Murtaugh's statement 11, you've really got to talk to the patient and family about their prevalence. That is a level A recommendation, something that really needs to be talked about from the beginning. All right, so now we've progressed to day 11. The family has requested aggressive treatment, as we discussed earlier. Is this patient appropriate for PEG and Trach? Should we extubate and see how he does? He is able now to open his eyes spontaneously during the day. The eye opening has no obvious trigger. Eye opening continues for minutes at a time before closing in. So at last, the PMNR consult is placed by the trauma team. What does your PMNR evaluation look like? I think everyone has a different flavor, but nobody does it as well as Dr. Weintraub. He's going to give us a few of his thoughts on what makes a good PMNR evaluation on these patients. So, I mean, this is your classic neurotrauma evaluation. I agree with everything that's been said. One comment I wanted to make on the CT. This has been looked at scientifically. If you see intraventricular hemorrhage in the setting of everything else, you know there's DAI. So say there wasn't all those kind of white matter, punctate, traumatic axonal injuries, but there was IVH. You can feel fairly certain that you will need an MRI scan to better understand the injury. Now remember, when you get your MRI scan, it's going to be a very dramatic looking picture in terms of blood byproducts related to axonal injury. But even that is not that prognostically helpful. So you do a comprehensive medical evaluation, look at confounding variables. What other comorbidities could be interfering with not just wakefulness, but awareness and purpose in your examination? I would further the examination in a much more specific way. And I'll defer to Dr. O'Brien to talk a little bit about that. And I would order in my entire team of speech therapy, physical therapy, occupational therapy for a comprehensive quantitative bedside evaluation. And we use the coma recovery scale revised for that. Look at the confounding effects of any neurological factors. Does the patient have any extra axonal masses that are developing? Are they developing post-traumatic hydrocephalus? Do they need continuous EEG monitoring to deal with ictal or interictal phenomena? The most common thing you're going to see in the ICU is the deleterious effect of medications suppress arousal, initiation, and purpose. And in particular, it's going to be medication used to manage paroxysmal sympathetic hyperactivity, also known as storming. By the way, storming does not have a correlation to prognosis or outcome, but it keeps everyone up all night for weeks to two weeks. So there becomes their subjective discussion around that. The medicines that are used for that are beta blockers, first line, and frequently the ICU patient will be on other kind of suppressive medications. Again, warranting the humble nature of how you need to approach this with I don't knows. We have to see how patients do once they're off all sedating medications. To me, the physical somatosensory communicative and cognitive assessment is all based on how uniquely you do a quantitative CRSR or some other assessment. The only other diagnostic study that needs to be done on this patient, but you also need to put it in context, is MR imaging. And in particular, with looking closely at susceptibility weighted image sequences, never make a prognosis on a diffusion sequence. That just sort of shows the movement of molecules across cellular membranes and axonal planes, and often is just related to edema. But I see neurologists in the acute care setting making prognostication off that. The susceptibility weighted imaging, and perhaps the flare superimposed on that, gives you some idea of what the recovery pattern is going to be, not whether they're going to emerge consciousness. Stay together as a team, work closely together so that there's no splitting and dividing, and take care of your family in sensitive ways between balancing realistic information and not taking away their hope. Is that what you were looking for, Craig? Yeah, I think that's fantastic. Thank you. So what are we talking about here? So in our PM&R evaluation, this patient is able to open his eyes spontaneously. He does not track, at least as much as we can tell. He does frequently desaturate, and we discover no volitional movements. Would you feel comfortable at this time as an audience member giving this individual a diagnosis? And what diagnosis would you be? Well, typically when we're talking about disorders of consciousness, we're talking about three specific diagnoses or buckets, if you will. Number one would be a coma. That is no arousal and no awareness, no wakefulness, no perception, no communication, no movement. Scientifically, we typically think of this as having no sleep cycles on EEG. But when studied, coma is typically very short-lived. We're talking about maybe a few days at most. So after that, the diagnosis should probably be something else. And I think in Mr. Sutton, from the information we've given you, this hopefully is not where you are thinking this gentleman is at. The next possible answer would be what we are now to be calling this state unresponsive wakefulness syndrome. Those of us who have a few gray hairs may remember it as the vegetative state. In the vegetative state, the patient may or may not have spontaneous eye opening. There should be evidence of a shift on the EEG between sleep and wake cycles, but there's no definite or obvious awareness of self or awareness of the environment. And then finally, the last state within disorders of consciousness typically is the minimally conscious state. And what we're speaking to here is that there are definite signs of self and environmental awareness, but that they're inconsistent. They're struggling with maintaining those interactions. The things that typically bump someone from vegetative into minimally conscious would be things like showing or demonstrating an interactive communication or a functional use of object. If this has confused you, I apologize, but Dr. O'Brien is going to do a much better job than I ever could of describing this and the assessments on the next few slides. Okay. So recommendation 2A in the guidelines recommend that you standardize neurobehavioral assessments that are valid and reliable to improve your accuracy. One of the things that is most important is when these patients are coming to us from acute care, whether you've done an assessment in the acute hospital or just in your rehabilitation hospital, one-time assessment does not give us an accurate level of where this patient's at. So some of the other recommendations are to use multiple assessments. It doesn't have to be different types of assessments, but multiple time points over multiple days at different times of day. We want to use these because they give us a better indicator than informal bedside evals. Most of the patients that get to us are being asked, raise your arm, show me a thumbs up, and walking away within a few seconds when they're not moving. And what we found is that the standardized assessment scales can rule out about 42% of people who would be misdiagnosed solely by a bedside evaluation. This was Schnackers in 2009, and it is something that is strongly recommended that you use these scales. You use them frequently. Now, they're not possible in some settings, and it's not feasible in other settings. So they're working on actually a CRSR FAST for the ICU. And then just understanding what these scales do and how to quantify behavior is really important. So when I educate our residents and our fellows here at TIER, I always say, I don't expect you to understand how to use this scale. I want you to understand the construct that the scale is measuring and how we get to that construct so that you can then give this patient the best setup for success. So in terms of that, there are other assessment scales out there. The CRSR is the gold standard, as many have said. This is a six sub-scale-based test that's built hierarchically with the highest score being the most cortically based behaviors going down to reflexive and brainstem. Each administration starts at the highest and works your way down. So you always just give the patient the chance to achieve something higher. I can't tell you how many times a patient has come in labeled as vegetative, and the family will say they can't do anything. And if you put a pen or a cell phone in their hand, and all of a sudden they start using it or swiping on the phone, no one tried. And that's the biggest problem is if you don't try, you're never going to know. So that is why we recommend using the standardized scales. Again, five administrations over the course of two weeks is what the CRSR is recommended with to get a 95% confident interval in your level of consciousness in the patient. As Dr. DiTomaso mentioned, when you're talking about coma, vegetative, minimally conscious, and emerged, the boundary to show MCS is just showing signs of awareness of yourself or the environment. This could be MCS minus where they're showing visual tracking, visual fixation, but no language function. Or it could be intermittent command following or response to language where they're showing that they have that linguistic circuit intact. So the boundary to get to emerged would be evidence of functional communication, whether that's with head turns, arm movements, thumbs up, or functional object use. One of my favorites was found by a nurse where she told us, oh no, if you offer the patient a urinal, they know what to do. Now I'm never going to do that on a CRSR because they get 10 seconds to respond and I'm not going to pull a urinal away after 10. But these are things that you can glean from your team around you that help you put together all the information to make the best level of conscious statement for the families. Can I ask you a question, Catherine? Yes, please. So can you discuss the context for the exam, the CRSR, when done acutely as it relates to confounders? And the reason I wanted to ask that was there was a chat room, a question from Dr. Hecht on when you get an MRI. And I will say when I get an MRI is generally about 72 hours or sometime thereafter. And the MRI and the neuroanatomy of this injury helps me often put in context the bedside findings. As an example, if I see a left temporal contusion, I don't expect this patient to follow auditory commands quite as easily. Or if I see occipital edema, I'm not going to see them respond so well to visual threat on bedside exam. So can you comment on just the context of the CRSR when making these, I call them early, pre-two week or early decisions? Yes. So I think you brought up a great point. And I think the question is fantastic, though I don't know how many people practicing always have access to an MRI. So while if you have access to it, that's great. And I think using what you know about the neuroanatomical substrate of the injury to apply to your assessment is important. In terms of the behavioral assessment, we think of the things we can control behaviorally. So given that it's a standardized exam, the things that I can control are what time did the patient get their meds? Have they already gotten their stimulants? Did they just receive a pain medication? Did one of my favorites was the note I read that said patient didn't follow any commands, patient didn't do anything, but they were about 35 minutes post peg tube placement, likely still anesthetized from that surgical procedure. So not an ideal time to do a behavioral assessment on a patient. So putting them in positions that optimize their responding, whether it's raising the head of the bed as high as you can, to get them in a more upright position, opening all the windows, bringing light into the room, making sure they're getting good sleep at night. So the confounders that I can control are the ones around the environment and the setup of the patient. Now the medical team, I'm working very closely beside to talk about those things like the medications that we're about to talk about or any other confounders that may play a role. And I think we're going to get into some of these. So I think I'm going to defer the rest of that question. And as we persist through Michael Sutton's case. Perfect segue. So you as the physiatrist on this case, you're now worried that there may be other factors clouding your evaluation. When you review his medication list, these four medications jump out to you. I'll ask for anyone to put any thoughts they have in the chat room about which one or any of these medications that may be problematic. And then I'll give you my take. In the interest of time, I'm going to move just a little bit faster than we have. So this fits into guideline 2D, which is that clinicians should identify and treat conditions that may confound the diagnosis of DOC. And one of the big ones for me is always seizures or epilepsy. And as Dr. Weintraub mentioned, oftentimes in the ICU care, you can get monitoring or things to help you, but sometimes you're not in those settings where you have access to that. So what do we know about seizures? Well, hopefully most of the people on this Zoom know a bit about seizures, but if not, I've tried to break it down. I do think it's worth reporting in the Zang study, which Dr. O'Brien and I participated in, we found 29, basically 30% of our DOC rehab population were still struggling with epilepsies. Seizures identified by NEG can occur after traumatic brain injury, hypoxia, obviously, and you're looking for epileptiform discharges. Now, remember that even benign epileptiform discharges during rehab may predict seizure activity, but the same found during acute care do not seem to have as high of a risk for epilepsy. So in Mr. Sutton's case, I would ask you to think about the guidelines that have been published previously about seizure management, and that is that there are immediate seizures, those that happen at time of injury, early seizures, those that happen within seven days, and late seizures, those that happen more than seven days later, and if they continue after those seven days, we call it post-traumatic epilepsy. Now, the recommendation is for patients who are high risk, which of course traumatic brain injury almost always are, to treat that prophylactically for the first week and then to peel them off and see if you experience post-traumatic epilepsy, and that's level A evidence due on multiple randomized controlled trials. And so in Mr. Sutton's case, perhaps something, here's a chart to help break it down, perhaps removing the levotiracetam, which we all know can be somewhat sedating, may help to improve his participation. Problems with sedation, of course, problems with epileptic medication, sedation, slow learning, ataxia, and age-related. All right, so moving along, now you've got to make a choice on where this gentleman goes. As physiatrists, you're probably familiar with all of these locations. You want to jump into the chat box and let us know what you're thinking on that. What do you think would be the most appropriate next step for Mr. Sutton? And again, in the interest of time, I'll move a little bit quickly. This is, in fact, as you may have guessed, a trick question. Recommendation number one is that patients need to go to rehabilitation settings where people have the treatment and the skills to adequately treat them. It does not recommend that it has to be an LTAC, an inpatient rehab, or a skilled nursing facility. So if we were to have an insurance medical director on the call, I would strongly urge them to review these cases and consider that these individuals need placement in the appropriate settings based on AAN ACRM recommendations, and that that setting could be potentially any setting if they have the adequate resources. They need a multidisciplinary team, and they need specialized training as mentioned. So in our case, unfortunately, Mr. Sutton kind of gets lost into the ether of post-acute care. The exact level is not important. The important thing is he did not have specialized care. No one who was comfortable or had taken care of DOC patients was treating him, but he continued to improve. His family believed that he was trying to communicate. So he returns to your care, regardless, again, of where that's located, an LTAC, a rehab, or a SNF, four weeks after you've lost track of him and eight weeks after the initial. So what do you see on admission? The patient comes to your rehab service. There's no obvious volitional movement. There is, however, continued and ongoing spontaneous eye opening, and you now have questionable eye contact. You assemble your rehabilitation team. This is a typical team, but I will give Dr. Murtaugh a few minutes to just discuss the nature and the makeup of the team, as well as perhaps any other caveats we forgot. Yeah. So going back to that number one recommendation in the guidelines of that specialized interdisciplinary team to be able to medically manage, appropriately assess the patient, identify confounds, and keep that patient moving through their recovery, it doesn't specify what that team should look like. The minimal competency recommendations, however, does outline that a little bit more explicitly. In what I think is the traditional DOC team, your physiatrist is your lead physician, managing medications, again, trying to identify in consultation with the team if there's any potential medical confounds that are masking consciousness, PTOT speech, respiratory therapy, trying to make that, you know, help that patient be as respiratory, pulmonarily stable as possible, potentially getting them off the vent, potential trach decannulation, neuropsychology for that assessment piece. Depending on the team, it could be a combination of neuropsychology, speech, occupational therapy, and potentially physical therapy, completing those DOC assessments, such as the CRSR. Dietitian to monitor tube feeding and caloric intake, weight monitoring, are they staying stable? Are they losing, are they gaining weight? So that we're again, decreasing secondary complications such as pressure injuries, rehab nurses are so key because they're spending the majority of their time at the bedside, more than the rest of the team. And so they may be picking up on different responses or behaviors to different procedures that they're doing that we might not be seeing during our sessions. Pharmacy and then case management and social work are so huge, I think sometimes they are forgotten because they're not direct care clinicians, but they're helping to manage the whole case and be that in between of our healthcare system in the United States, the family, the care team and the entire care plan. And so they're an incredibly important piece to be communicating with and in the know because they're gonna be helping to manage the whole entire case. So that's kind of your traditional, I'm sure we've missed some, obviously family is a huge part of that team as well that should be constantly in communication with the team for education, but then they have some really big decisions that they're making from day to day. Absolutely, well said. So now this patient is in your service, you have more resources available to you. What would be your next step in assessing this gentleman? Would you want an fMRI? Would you pursue an EEG? Do you think the disability rating scale comes next or would you pursue another JFK coma recovery scale? I will of course, kick it to our neuropsychologist, Dr. O'Brien to discuss first. So based on what we know about the recommendations and obviously what I've already talked about, we wanna use the serial standardized neurobehavioral assessments. Truthfully an fMRI, while we have lots of patients that their family members are advocating for it because they've seen that literature, it's actually not a test that even some very conscious people can perform. So we prefer to find the consciousness from a behavioral standpoint. And once you have that, the fMRI would not provide anything above and beyond potentially what you already have behaviorally at bedside. So that is not necessarily your first level of what you're looking for with this patient. And obviously the DRS is very gross in terms of its measurement would not be very helpful at this level of care. And in EEG with biofeedback, again, there's people who can do that and there's people who can't. So receiving a negative result does not mean that the consciousness is not there. So really the number one recommend, well, it's the number two recommendation to be is number one, get them to rehab, which we're all preaching to the choir here at AAPMNR, but for those acute consults, getting them and then getting them in where they can have the serial assessments and look at this using the standardized measures. And then the frequency of such assessments can be assessed and reassessed based on and as needed basis. I know some facilities will do a CRSR every day. Some facilities do it twice a week. And then I think they also need to be individualized. Some CRSRs can be performed while in standing. So they're actually brought into the physical therapy session or into the occupational therapy session while they have the patient edge of map versus always approaching the patient while they're in bed, which is not setting them up for success. Anything further to say on using the serial standardized? Yeah, so lastly, number four, I think it's useful to look at these tests to kind of look at the trends. So the trends these patients are following, this can help us as a neuropsychologist, I really meet with my medical team regularly to look at the trend, have they plateaued? Why have they dipped? Did you change a medication? Did we do something different that caused this patient to lose the movement they already had or what have you? So are we seeing a change? Oh, do they have a sunken flap? Is that why we're seeing them kind of regress a little? So looking at the trends is important and then how you can use that to help establish a prognosis going forward. But again, making sure that you've gotten your 28 days under your belt and several assessments. I will never talk to a family about my findings and what they mean until I've gathered enough. I will tell them what I saw, what that means, but I say I won't confirm it until I've done it again. Too many times have I seen a patient have kind of almost a hyperkinetic movement disorder that allows them to get points on a CRSR just by chance that as you get to know the patient better, you realize that it is by chance. A quick question for the panelists. Once your patient starts to emerge consciousness and say they're localizing or even agitated, do you continue to use the CRSR or is it that point clinically you start to employ other metrics and ways of more specifically managing components of their emerging disability recovery pattern? In other words, why would you keep using the CRSR once they've evolved past the minimally conscious state and they're demonstrating say aphasia, apraxia, pleja, et cetera? What are your thoughts on that? So Dr. John White came out with a methodology called an individualized quantitative behavior assessment. And these can be used to look at very specific questions for your patients. So once I already have a minimal conscious or I think I have command following, if I wanna look at true language function or I want to look at something more specific like vision, we can use this methodology of an end of one experimental design to collect data, to quantify what we're seeing in these patients. So it can push us in that direction. And then in terms of your question, Dr. Weintraub, I would also continue until I felt that this person has gotten past a lot of the big acute changes we make when they first come into rehab, just to show if we do have a dip or decline, we can time base it with the medication changes and see what has impacted them. We're getting very short on time. We will probably not complete the PowerPoint, but we'll get as far as we can. Okay, everybody. I apologize for that. So he's into your rehab. Initial JFK coma recovery scale seems to be about eight. He is trying to talk and move his left arm. Physical examination though is largely unremarkable otherwise. PT demonstrates eye opening during standing and SLP documents no obvious verbal communication. He's making slow progress with the rehab efforts. Do you decide to add a pharmacological intervention? Which medication is best supported for neurological recovery in this population? Amantadine, methamphetamide, Denapazil, or Bacl? And again, in the interest of time, moving forward. So recommendation 14 says that patients who are four to 16 weeks post-emergy should receive Amantadine 100 to 200 milligrams to improve the functional recovery and reduce disability. And that was a level B recommendation based mostly on the Giacino and White study published in the New England Journal of Medicine. On that note, I will say that the Amantadine did improve recovery and improve the rate of recovery. And there was some evidence that it was a medication effect, meaning that if you stop the medication, after they stopped the medication, I should say that the effect was less. In addition, although not statistically significant, the Amantadine group was slightly less impaired than the control group. But overall, there were fewer patients in the vegetative state after the medication was administered. So it does have evidence behind it. That is all just to say, though, that pharmacological intervention after brain injury is very nuanced, right? We have lots of different agents that are used in the field. Dr. Weintraub and I may be looking at the same patient and have slightly different feels about what they need and which medication will help them the most. And to be honest, we don't always have a lot of evidence about who's right and who's wrong. And so you have to just kind of refine your craft and learn your medications and you do the best you can. Amantadine does seem to have some evidence, but that doesn't mean, lack of evidence doesn't mean that there is no effect for the other one. Anything major I missed, Dr. Weintraub, we're getting awfully short on. Excellent. Unfortunately, Mr. Sutton then had, after a bit of progress with the Amantadine, had a downturn. He was hyperthermic and lethargic during his occupational therapy session. You reevaluate him and find an average size man resting in bed, mildly diaphoretic with his eyes closed, non-responsive to verbal stimuli and a pungent urine smell in the room. Which of the following diagnoses should be lower or perhaps better said should be lowest on your differential and which other diagnoses should you rule out first? If you want to take a second and put them in their chat, I can't give you much time, I apologize. We're running very, very low. So the lowest one in differential should be bowel obstruction. We now have, not great, not even good, but some epidemiological data within the disorders of conscience population, specifically in inpatient rehab. Again, I'll cite the Zhang study that Dr. O'Brien and I contributed to. And we know that all of the other options, storming obviously we talked about can be very common, although usually it's calm or improved by the time they get to rehab. Heterotopic ossification can be fairly common and urinary tract infections almost ubiquitous within this population. So all of those should be much higher, probably urinary tract infection highest given the frequency. And that fits into recommendation both one and 12. Number one, meaning that clinicians need to work on medical stability and be comfortable with the complications that occur in disorders of consciousness. And 12, that you need to have a systemic way of working through these patients and identifying the complications that could obscure evaluation and treatment. And again, if you're interested in learning more about this, these are the three best studies in my opinion. And again, I'm very biased towards the Zhang study because I did have a role in the creation. So after we treat the urinary tract infection, the JFK coma recovery scale improves to 12. The gentleman is now able to fixate on objects during the examination. And there were inconsistent reports of him trying to communicate, but it is non-functional. So we are now preparing for discharge. Mr. Sutton has improved in the following areas. He's now standing with physical therapy. He is engaging in basic hygiene with occupational therapy. And he does attempt to communicate verbally at this point, but not well. He is however profoundly impaired cognitively and his insurance provider and their infinite wisdom has decided that no further rehabilitation will be supported. And he now needs a placement. Sometimes they'll use the word custodial. So the rehab team has decided to schedule a family conference to review the progress made during rehabilitation. And so I'll ask both Drs. Murtaugh and O'Brien to talk a little bit about successful keys to transition and needs and demands of the family. Yeah, so depending on what level of care you're practicing in, whether it's acute or LTAC, ARU, you transition to that next lower level of care comes with many factors to consider. Ideally, and I work in IRF, but we're always trying to get those patients home if that is the best option for the patient and the family's wants and needs and their wishes. But it's always planning ahead. From the time that they come into your service, thinking down the road of what is it gonna take to transition this patient to a home or community setting? What are their medical needs? What are the family dynamics? Do they require, which many times they do 24-hour care, what does that look like for the family to be able to provide? What is insurance saying that's such a huge driver in our healthcare system, whether it's a private third-party payer or Medicare or Medicaid, what are they allowing us to have for time? Because sometimes it's not very long, maybe two to three weeks, and how do we get that patient and family prepared for a transition in that amount of time and to what lower level of care? So that's where that interdisciplinary planning and team collaboration comes in because everybody's thinking in their own paradigm, but it's beneficial to the team because then hopefully every single scenario and patient and family need has been thought about and those resources set up to support a successful transition to the next level of care, whatever that may be. That could be a whole lecture in and of itself. And I'll just add, again, the resources in the community as well and what they have access to. If you're in a big city, if you're in a smaller town, if you have access to good home health, not good home health, these should all play a role and the family should be at the forefront of those decisions and what's best for that patient and what the patient would want. In the interest of time, we're gonna move forward. We've covered this already. So just a little bit about prognostication and outcomes. I think that all too often, people have a very negative view of patients with disorders of consciousness, but we do have some longitudinal outcomes. And Dr. Nakase Richardson's study in 2012 looked at 396 patients within the DOC, with DOC in the model systems, and 68% of those patients were able to recover consciousness during their inpatient rehabilitation stay. 23 progressed all the way to emerging from post-traumatic amnesia and 68% discharged to the community. So that goes back to recommendation number three, talking about that patients really do need this kind of structure around them. Those same patients were followed up at five years. So again, this publication went under Dr. White's name. And at this time we were down to 108 participants. Dr. White split them into two groups. 72% were the early recoveries. Those were the patients who were following commands prior to rehab discharge. And at this time, all of them were independent on some activity. Well, at time of discharge, all of them were independent on some activity. At five years, 56% of them were able to problem solve independently and 85% were able to mobilize independently, whether it's wheelchair ambulation. So at five years, the people who were responding to rehab during rehab make very good progress, right? What about the people who didn't though? 36 participants were followed who were not following commands at discharge. And at five years, 20 to 36% of them were independent in something on the FIMS score. So even if they didn't make the recovery during rehab, it doesn't mean that they weren't able to recover later. And I would argue perhaps rehab set the foundation or the ground level for that recovery after they were discharged. What about 10 years after this? So this one got published under Dr. Hammond's name and they followed 110 of these patients for 10 years after their DOC admission to a model system. At that point, 10 years later, 79% of them were able to walk. 72% of them were bathing independently, excuse me. 79% were independent with bowel management and 57% were independent from memory. For patients who had disorders of consciousness during inpatient rehab, it's really impressive long-term outcomes. It goes to show that perhaps rehabilitation is about more than just the immediate goals that we set, but can even set the groundwork or support these patients as they transition to long-term care. So we have just a few minutes. No, we don't. We are totally out of time. So I will put this slide up. This is a gentleman who I'm very close with. His name is Danny Fernandez. He had a severe traumatic brain injury, was in a disorder of consciousness, came to my rehab and then left and came back six months later for outpatient. And this is him progressing through each step. And you can see that there really are great outcomes in this population. You just have to really have a big heart and treat them and love them so that they can do it. I think we have two minutes. I'm gonna ask a question. I think that faces every one of these physiatrists doing a question in the ICU. How do you get this patient into your rehab? Do they meet the criteria for the quote three-hour Medicare rule for being participative? And what do you do when you're consulting on this patient to make a case? Let's just say this man's three weeks post-injury, he still has a low CRS score on the verge between vegetative and minimally conscious. How do you make a case for bringing that patient into rehab and not applying the traditional three-hour Medicare rule to this patient population? So I'll say if he's already on the verge of showing minimally conscious, I'm actually probably punting him to our brain injury program and not even the DOC program if he's three weeks post. In terms of three hours, we give every patient in our building, no matter what program you're in, three hours. And our therapists that treat DOC say they have enough work that they could do five hours. So doing the positioning, getting the management, getting them upright, keeping their vitals stable in an upright position, doing tilt table, doing all the different things we need to do, casting, serial casting, positioning, that takes time and that's active participation and rehabilitation. So I actually would argue, one, they meet the three-hour rule and two, a patient that's only three weeks post-injury already minimally conscious, I would actually put out of the DOC program and put in a typical brain injury program, at least in my setting. I would second everything Dr. O'Brien said. Being a bedside clinician OT with DOC, we can't get everything in in three hours. We sometimes need four or five. They may not be an active participant yet, but that's the goal is to get them there. And we have so many things we need to be managing and doing every single day. And I would just say- I wanna thank the presenters. I wanna thank this amazing 150 plus audience for their questions in the chat room. There is an article in JAMA Neurology this year that you can use, keep in your hip pocket that looked at these patients four weeks post-injury that went into rehabilitation. This is a TBI model systems cohort, over 15,000 patients, 800 of which had DOC one month post-injury and went into your inpatient rehab units. They emerged consciousness, 80% of these patients, 80% of the time, and the scores they made and changes they made on their FIM scores was more than a conscious participative cohort that entered rehab. So take note of that. They do improve as much as your other patients that meet the three-hour rule criteria, but they don't improve to as high of level. So from an ethics standpoint, it's sort of our obligation as primary care physicians to serve those with significant disabilities, to get them a good foundation as they plan for their new life. And I would encourage everyone on the call to email the presenters who have a wealth of scholastic and clinical experience and are available to you. And thank you for those who've made some really relevant clinical comments in the chat room. I think we have a hard stop though. That's what we were told. Yes, four minutes ago. Thank you, everyone. Thanks.

severe traumatic brain injury

non-traumatic acquired brain injuries

disorders of consciousness

neurological examination

interdisciplinary team approach

family involvement in care

evidence-based guidelines

JFK Coma Recovery Scale Revised

pharmacological interventions

rehabilitation progress