Development and reliability and validity testing of the assessment scale for patients with persistent vegetative state or minimally conscious state discharge from the anesthesia recovery room / 中国实用护理杂志

Objective:To develop and test the reliability and validity of the assessment scale for patients with persistent vegetative state (PVS) or minimally conscious state (MCS) discharge from the anesthesia recovery room after operation.Methods:From September 2018 to October 2020, three dimensions and 17 item pools were determined through literature review and discussion among the project members. Two rounds of expert consultation were conducted to determine the respiratory (R), circulatory (C), oxygenation (O), bispectral index (B) and neuromuscular monitoring (N) scale (RCOBN scale), the reliability and validity were tested. 87 patients with PVS or MCS after operation Affiliated Sichuan Bayi Rehabilitation Center of Chengdu University of Traditional Chinese Medicine were selected to verify the effectiveness.Results:In the first round, 23 questionnaires were distributed. The total score of experts was 50 ± 3, F=9.24, CV were 0.00-0.43. The Cronbach α coefficient of each dimension was 0.782-0.846, and the Cronbach α coefficient of the total scale was 0.813. In the second round, 10 questionnaires were distributed. The item-level content validity index was 0.7-1.0, the probability of random consistency ( Pc) was 0.001-0.117, the adjusted kappa value ( k*) was 0.567-1.000, and the sum of the index scores corresponding to k* > 0.74 was 8. The scale-level content validity index of the overall consistency was 0.87. The ratio of patients transferred out of PACU by two rounds of evaluation method was 100 : 96.55, and the difference was not statistically significant ( χ2=3.05, P>0.05). The time of the first round of assessment was significantly longer than that of the second round, which were (197 ± 52) s and (58 ± 14) s respectively. The difference was statistically significant ( t=26.52, P < 0.01). Conclusions:The RCOBN scale has high reliability and validity. It can be used as an assessment scale for patients with PVS or MCS to transfer out of PACU after surgery, and those with a total score of 8 can be transferred out of PACU.

Clinical and neuroimaging determinants of minimally conscious and persistent vegetative states after acute stroke

BACKGROUND: Patients with persistent vegetative state (PVS) show no evidence of awareness of self or their environment, and those with minimally conscious state (MCS) have severely impaired consciousness with minimal but definite behavioral evidence of self or environmental awareness after stroke. Neuroimaging and clinical characteristics separating these two close consciousness states after stroke were insufficiently studied. METHODS: We conducted a hospital-based cohort study of all patients with stroke (2011 to 2017) who underwent 3T magnetic resonance imaging and consciousness assessment after 3 months of inclusion. Univariate and multivariate regression analyses were used to estimate the relative risk of neuroimaging markers for differentiation of PVS and MCS. RESULTS: Of 3,600 eligible subjects, 323 patients (0.09%) had PVS and 93 (0.02%) had MCS (mean age, 62.25±13.4 years). Higher stroke volume was strongly associated with PVS compared to MCS (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.98 to 1.00; P=0.001). On univariate analysis, cingulate gyrus (OR, 2.7; 95% CI, 1.62 to 4.36; P=0.001) and corpus callosum (OR, 2.1; 95% CI, 1.28 to 3.44; P=0.003) involvement was significantly associated with PVS. However, on multivariate analysis, only cingulate gyrus involvement was independently associated with PVS (OR, 2.2; 95% CI, 1.33 to 3.72; P=0.002). CONCLUSION: Our results indicate that PVS and MCS are different consciousness states according to clinical and neuroimaging findings. To predict outcome, cognitive performance of these patients should be well questioned after stroke.

Validation of Korean Version of Coma Recovery Scale-Revised (K-CRSR)

OBJECTIVE: To determine the validity and reliability of the Korean version of the Coma Recovery Scale-Revised (K-CRSR) for evaluation of patients with a severe brain lesion. METHODS: With permission from Giacino, the developer of the Coma Recovery Scale Revised (CRSR), the scale was translated into Korean and back-translated into English by a Korean physiatrist highly proficient in English, and then verified by the original developer. Adult patients with a severe brain lesion following traumatic brain injury, stroke, or hypoxic brain injury were examined. To assess the inter-rater reliability, all patients were tested with K-CRSR by two physiatrists individually. To determine intra-rater reliability, the same test was re-administered by the same physiatrists after three days. RESULTS: Inter-rater reliability (k=0.929, p < 0.01) and intra-rater reliability (k=0.938, p < 0.01) were both high for total K-CRSR scores. Inter- and intra-rater agreement rates were very high (94.9% and 97.4%, respectively). The total K-CRSR score was significantly correlated with K-GCS (r=0.894, p < 0.01), demonstrating sufficient concurrent validity. CONCLUSION: K-CRSR is a reliable and valid instrument for the assessment of patients with brain injury by trained physiatrists. This scale is useful in differentiating patients in minimally conscious state from those in vegetative state.

Spatial Properties of Mismatch Negativity in Patients with Disorders of Consciousness / 神经科学通报·英文版

In recent decades, event-related potentials have been used for the clinical electrophysiological assessment of patients with disorders of consciousness (DOCs). In this paper, an oddball paradigm with two types of frequency-deviant stimulus (standard stimuli were pure tones of 1000 Hz; small deviant stimuli were pure tones of 1050 Hz; large deviant stimuli were pure tones of 1200 Hz) was applied to elicit mismatch negativity (MMN) in 30 patients with DOCs diagnosed using the JFK Coma Recovery Scale-Revised (CRS-R). The results showed that the peak amplitudes of MMN elicited by both large and small deviant stimuli were significantly different from baseline. In terms of the spatial properties of MMN, a significant interaction effect between conditions (small and large deviant stimuli) and electrode nodes was centered at the frontocentral area. Furthermore, correlation coefficients were calculated between MMN amplitudes and CRS-R scores for each electrode among all participants to generate topographic maps. Meanwhile, a significant negative correlation between the MMN amplitudes elicited by large deviant stimuli and the CRS-R scores was also found at the frontocentral area. In consequence, our results combine the above spatial properties of MMN in patients with DOCs, and provide a more precise location (frontocentral area) at which to evaluate the correlation between clinical electrophysiological assessment and the level of consciousness.

The clinical curative effect of transcranial direct current stimulation on patients with disorders of consciousness / 中华物理医学与康复杂志

Objective To assess the clinical efficacy of transcranial direct current stimulation (tDCS) in improving consciousness in patients with severe disorders of consciousness.Methods Thirty-eight patients with disorders of consciousness were divided into an observation group and a control group according to a random number table,each of 19.Both groups received conventional rehabilitation therapy,while the observation group was additionally provided with tDCS at the intensity of 2 mA for 20 minutes per day,6 days per week,for 20 times,with the anodal electrode (isotonic saline gelatin sponge,7 cm×5 cm) placed over the left dorsolateral prefrontal cortex and the cathodal stimulation over the right eye socket or right shoulder.The patients were evaluated with brainstem auditory evoked potential (BAEP),upper limb somatosensory evoked potential (USEP),electroencephalogram (EEG) and Glasgow coma scale (GCS) and persistent vegetative state (PVS) scores before and after the treatment.Results There were no significant differences between the two groups with regard to BAEP,USEP,EEG,GCS and PVS scores (P＞0.05).After the treatment,significant improvement was observed in all the measurements,with those of the observation group superior to the control group (P＜0.05).In the evaluation of clinical efficacy,the total effective rate and the significant effective rate of the observation group was 89.47％ and 78.95％,respectively,significantly higher than those of the control group (84.21％ and 42.11％) (P＜0.05).Conclusions Conventional rehabilita tion treatment can improve the BAEP,USEP,EEG,GCS and PVS scores of patients with severe disorders of con sciousness,and the addition of tDCS on the basis of conventional rehabilitation treatment is more effective.

A comparative study of the effect of a single transcranial direct current stimulation on resting state of brain functional network in patients in a minimally conscious state / 中华物理医学与康复杂志

Objective To investigate the effect of transcranial direct current stimulation (tDCS) on the amplitude of low-frequency fluctuation (ALFF) of the resting brain function network in patients in a minimal conscious state (MCS) so as to explore the mechanism.Methods Eleven MCS patients were selected.Among them,there were 9 males and 2 females,10 with cerebral trauma and 1 with cerebral hemorrhage,with an average age of (37.3±8.4) and an average course of disease of (3.4±0.1) months.All subjects were given a resting-state functional magnetic resonance imaging (rs-fMRI) assessment prior to the single tDCS treatment,followed by a 20-minute single sham tDCS treatment at a time.After single-sham stimulation,a second time rs-fMRI assessment test will be conducted,followed by a real tDCS treatment for 20 minutes.Eventually,a third time rs-fMRI assessment test will be implemented.Results No significant statistical difference was shown in terms of all the parameters after single shamtDCS as compared to those before the treatment (P＞0.05).After single real-tDCS,no significant change was observed with CRS-R score,ALFF of default network (left anterior wedge),the frontal-parietal network (left fróntal lobe,right superior gyms),sensory motor network (left auxiliary motor area),subcortical network (right thalamus,bilateral caudate nuclei) was significantly higher than that before treatment,while the ALFF of the frontal network (frontal lobe) and auditory network (bilateral temporal lobes) was significantly decreased (P＜0.05).After single real-tDCS,the ALFF of default network (right frontal lobe) was significantly enhanced compared to that after single sham-tDCS (P＜0.05),while that of the salient network (left insula) and sensorimotor network (right central frontal) was significantly decreased (P＜0.05).Conclusion The enhancement of ALFF activity in the resting state brain function network is a possible neural mechanism for tDCS to promote the recovery of consciousness level in pa tients with minimal conscious state.

Research Progress of Music Therapy for Patients with Disorders of Consciousness after Brain Injury (review) / 中国康复理论与实践

@#The recovery of disorders of consciousness after brain injury is very difficult, music therapy is one of the important ways to promote the awakening. The effects of music therapy are various among individuals, the vegetative state and the minimally conscious state, and the pieces of music. The default mode network is one of the most important networks to maintain awareness, which many other networks participate in. The brain regions affected by music involve in many networks, including hearing, cognition, emotion, and so on.

The state of consciousness in patients in the vegetative and minimally conscious states / O estado de consciência em pacientes em estado vegetativo e em estado de consciência minima

Brain-injured patients may, with the assistance of life support, continue to perform basic bodily functions, but yet be deficient in wakefulness, awareness, decision making or other overt manifestations of consciousness. Here, we review two neurological states observed in brain injured patients with different degrees of brain impairment, the vegetative state (VS)and the minimally conscious state (MCS), and we discuss how these states are diagnosed through assessing patient behavioral responses during clinical examination. We consider howfunctional neuroimaging has revealed preserved cognitive capacities in patients that were supposed to be in the VS and has introduced a new diagnosis, cognitive motor dissociation.We review the GW Theory proposal that consciousness arises from functional connectivity (FC) of widely separated brain regions. We discuss how such high FC underlies the DefaultMode Network (DMN), a group of neural circuits that are active when an individual is not involved with external tasks and engages in introspective thinking. Finally, we discuss thefinding that the level of FC of the DMN is diminished in brain injured patients and the proposal that the level of residual DMN FC in brain injured patients is an index of their consciousness

Pacientes com lesão cerebral, quando assistidos, podem continuar a desempenhar funções fisiológicas básicas, mesmo estando com a vigília, a atenção, a capacidade de decisão e outras funções de consciência prejudicadas. Revisamos aqui dois níveis de distúrbio de consciência o estado vegetativo (VS) e o nível de consciência mínima (MCS), e discutimos como são diagnosticados através das respostas comportamentais durante o exame clínico. Abordamos como a neuroimagem funcional revelou capacidades cognitivas preservadas em pacientes supostamente em estado vegetativo, introduzindo um novo diagnóstico: a dissociação cognitivo-motora. Revisamos a proposta da Global Workspace (GW) teoria de que a consciência surge a partir de um alto grau de conectividade funcional (FC) entre áreas cerebrais distantes. Discutimos como esta alta conectividade é a base do Default Mode Network (DMN), uma rede neural ativada quando o indivíduo não está envolvido com tarefas externas e se volta para atividade mental introspectiva. Finalmente, discutimos os achados de redução do nível de FC no DMN em pacientes com lesão cerebral e a proposta de que o mesmo poderia ser um índice do nível de consciência nesses pacientes.

Condition and Related Factors of Anxiety and Depression in Caregivers of Patients in Persist Vegetative State or Minimally Conscious State / 中国康复理论与实践

Objective To explore the anxiety and depression in caregivers of patients in persist vegetative state and minimally conscious state, and discuss the related factors. Methods From January, 2010 to December, 2014, 60 caregivers of 60 patients in persist vegetative state and minimally conscious state were assessed with Self-rating Anxiety Scale (SAS) and Self-rating Depression Scale (SDS). The sex, ed-ucation level, relation to the patients and family income of the caregivers, and the age of the patients and number of the families of the pa-tients were recorded, and analyzed with Logistic regression. Results 55％caregivers were found in anxiety, and 48.4％in depression. The fe-male caregivers (OR>6.870, P<0.05), the number of the family of the patients (OR<0.233, P<0.05) and age of the patients (OR<0.294, P<0.05) were independent factors associated with anxiety and depression. Conclusion The caregivers of patients in persist vegetative state and minimally conscious state are troubled in anxiety and depression, especially the female, while age and the number of the families of patient may be important factors for it.

Advance in Minimally Conscious State (review) / 中国康复理论与实践

@#This paper summarized the concept, diagnostic criteria, clinical treatment, outcome and the current issues faced of minimalconscious state.

Advance in Minimally Conscious State (review) / 中国康复理论与实践

This paper summarized the concept, diagnostic criteria, clinical treatment, outcome and the current issues faced of minimal conscious state.

The preliminary study of the sensitivity of clinical consciousness scales to patients with disorders of consciousness / 中华急诊医学杂志

Objective To evaluate the sensitivity of three different clinical consciousness scales to patients with disorders of consciousness.Methods A total of 84 patients in vegetative state (VS) were selected and scored by the consciousness scales including Glasgow Coma Scale (GCS),Coma Recovery Scale-Revised (CRS-R) and Chinese Vegetative State Scale (CVSS) respectively.The patients were followed every 2 weeks for 12 weeks or every 4 weeks for 12-24 weeks.The assessment finished in 6 months or till the time when patients emerged from minimally conscious state ( MCS.The diagnostic sensitivity and the sensitivities of each sub-scale in CRS-R were evaluated when the patients with MCS emerged from VS.The diagnostic consistency with other scales was observed and analyzed by Spearman correlation as well.The Spearman -relate was used to analyze the correlations among the total scores of three scales in the patients on admission (36 patients with acute and 48 patients with chronic phase).Results Of 84 VS patients,there were 47 emerged to MCS.CRS-R was the most sensitive in the diagnosis of MCS (P ＜ 0.05 ) among all scales.The visual subscale is the most sensitive among all the CRS-R subscales ( P ＜0.01 ).Among the 84 patients,the remaining 37 were diagnosed as VS by all three scales.The total scores correlation analysis showed that the score of CRS-R significantly correlate with that of GCS in acute and chronic phase ( P ＜0.01 ) and significantly correlate with that of CVSS only in the acute stage ( P ＜ 0.05 ).Conclusions It is indicated that CRS-R,especially the visual subscale of CRS-R is the more sensitive tool for detecting.MCS during recovery process in the disorders of consciousness.As to the patients with deep unconsciousness and with no significant recovery,the three instruments are in good agreement to determine the degree of disorders of consciousness.It is suggested that CRS-R can be widely used to assess the level of consciousness in various stages.

A Learning Set Up for Detecting Minimally Conscious State (MCS)

Detecting signs of learning in persons diagnosed to be in a post-coma vegetative state and minimally conscious state (MCS) may modify their diagnosis. We report the case of a 65-year-old female in a vegetative state. We used microswitch-based technology that is based on patient response to eye-blinking. We followed an ABABCB design, in which A represented baseline periods, B intervention periods with stimuli contingent on the responses, and C a control condition with stimuli presented non-contingently. We observed the level of response during the B phases was higher than the level of A and C phases. This indicated the patient showed signs of learning. This state was confirmed by an evaluation through the Coma Recovery Scale-Revised (CRSR) score, and after completion of this study her CRSR score changed from 4 to 10. We believe microswitch technology may be useful to make a diagnosis of MCS and offer new opportunities for education to MCS patients.

A Learning Set Up for Detecting Minimally Conscious State (MCS)

Detecting signs of learning in persons diagnosed to be in a post-coma vegetative state and minimally conscious state (MCS) may modify their diagnosis. We report the case of a 65-year-old female in a vegetative state. We used microswitch-based technology that is based on patient response to eye-blinking. We followed an ABABCB design, in which A represented baseline periods, B intervention periods with stimuli contingent on the responses, and C a control condition with stimuli presented non-contingently. We observed the level of response during the B phases was higher than the level of A and C phases. This indicated the patient showed signs of learning. This state was confirmed by an evaluation through the Coma Recovery Scale-Revised (CRSR) score, and after completion of this study her CRSR score changed from 4 to 10. We believe microswitch technology may be useful to make a diagnosis of MCS and offer new opportunities for education to MCS patients.

Neurobiología de la conciencia / Neurobiology of consciousness

Los desórdenes de la conciencia continúan fascinando a neurólogos, neurocientíficos y filósofos pero durante décadas no han sido objeto de estudios consistentes debido a su dificultad en el abordaje experimental. En los últimos años, un creciente número de grupos de investigación en neurociencias cognitivas están abordando el estudio de la neurofisiología de la conciencia desde una perspectiva experimental a pesar de la complejidad metodológica y epistemológica del tema. Aunque es difícil de describir la conciencia, ésta podría ser definida como una combinación entre la capacidad de estar en vigilia (wakefulness) y el hecho de estar consciente (awareness). Desde una perspectiva neurobiológica se ha propuesto que el sistema de la formación reticular ascendente y sus proyecciones talámicas serían críticos en modular el ciclo sueño vigilia y el alerta (wakefulness). La capacidad de darse cuenta conscientemente (awareness) sería una función de las redes neurales entre la corteza y el tálamo y el sistema córtico-cortical. Distintos modelos se han utilizado al atacar este difícil problema; estudios in vivo no invasivos, en personas conscientes con lesiones cerebrales, en animales y en personas en estados de conciencia disminuida. En este artículo revisamos la evidencia científica de los correlatos neurales de los procesos conscientes e inconscientes en diferentes estados de conciencia haciendo hincapié en pacientes en estado de conciencia disminuida.

Disorders of consciousness have captivated neurologists, neuroscientists, and philosophers for decades, but few consistent studies have been conducted on these conditions due to their difficult experimental approach. In recent years, an increasing number of cognitive neuroscience research groups have examined the physiology of consciousness from an experimental perspective, despite the methodological and epistemological complexities of the field. While describing consciousness can be challenging, a close definition must acknowledge a combination of wakefulness and awareness. Form a neurobiological standpoint; it has been argued that the ascending reticular system and its thalamic projections are critical in modulating awareness and wakefulness sleep cycles. Awareness may be a function of the neural networks within the cortex, the thalamus, and the cortico-cortical system. Different models have been employed to tackle this difficult problem, including non-invasive in vivo studies, examination of conscious patients with brain lesions, and studies on both animals and patients with disorders of consciousness. This article reviews the scientific evidence for the neural basis of conscious and unconscious processes in different states of consciousness, focusing on patients in the vegetative and minimally conscious state.

Assessment of Patients with Minimally Conscious State: Recent Advances

Sometimes we heard that a person with persistent vegetative state could not change or suddenly recovered in terms of an emergence of purposeful movement or any form of communication. The prediction of recovery of these patients is a valuable for physicians and caregivers. Therefore defining and establishing diagnostic criteria for the vegetative state (VS) and minimally conscious state (MCS) is a meaningful; MCS differs from the VS by the presence of inconsistent, but clearly discernible, behavioral evidence of consciousness, and it has a more possibility to recover than VS. I will review some new measurements, including behavioral, neuroimaging and neurophysiologic methods, to identify the difference between VS and MCS.

Emerging Therapies in Vegetative and Minimally Conscious State after Brain Injury

The practice of coma arousal and brain stimulation in vegetative state or minimally conscious state is becoming the focus of heated debate. There is no definite theory on which patients may benefit, at what time in their recovery, or how the 'arousal' or 'stimulation' procedures should be applied. In this review, old and new therapeutic methods for recovery of vegetative state or minimally conscious state will discussed. And we consider some of the information processing mechanisms that are important mediators of arousal and awareness in current practices.

Evaluation of the consciousness scales in the diagnosis of the severely impaired consciousness / 中华急诊医学杂志

Objective To evaluate the commonly used consciousness scales according to longitudinal study on small-sample patients with minimally conscious state. Method Eleven patients with minimally consciousness, who were scanned using fMRI, were selected and scored by the commonly used consciousness scales in Wujing Hangzbeu Hospital. The 11 patients were classified into 2 groups according to the scores of CRS-R scale couple with the results of the fMRI study. The One-Way ANOVA method was used to analyze the inter-group difference of the commonly used consciousness scales and their subscales. Results Despite the communicative subscale of the CRS-R scales, other iterms lack of statistic significance in classification of the conscious state. Among the commonly used consciousness scales, the Wessex Head Injury Matrix (WHIM) scale presented the highest diagnostic value in consciousness state, whereas the Chinese Vegetative State Scale (CVSS) presented the lowest diagnostic value. Conclusions It indicated that the total scores of the consciousness scales and the scores of subscales of them presented poor diagnostic value in general, and big discrepancy of diagnostic value existed between the iterms of the scales by using objective tools.