Unresponsive wakefulness syndrome: a new name for the vegetative state or apallic syndrome.

BACKGROUND: Some patients awaken from coma (that is, open the eyes) but remain unresponsive (that is, only showing reflex movements without response to command). This syndrome has been coined vegetative state. We here present a new name for this challenging neurological condition: unresponsive wakefulness syndrome (abbreviated UWS). DISCUSSION: Many clinicians feel uncomfortable when referring to patients as vegetative. Indeed, to most of the lay public and media vegetative state has a pejorative connotation and seems inappropriately to refer to these patients as being vegetable-like. Some political and religious groups have hence felt the need to emphasize these vulnerable patients' rights as human beings. Moreover, since its first description over 35 years ago, an increasing number of functional neuroimaging and cognitive evoked potential studies have shown that physicians should be cautious to make strong claims about awareness in some patients without behavioral responses to command. Given these concerns regarding the negative associations intrinsic to the term vegetative state as well as the diagnostic errors and their potential effect on the treatment and care for these patients (who sometimes never recover behavioral signs of consciousness but often recover to what was recently coined a minimally conscious state) we here propose to replace the name. CONCLUSION: Since after 35 years the medical community has been unsuccessful in changing the pejorative image associated with the words vegetative state, we think it would be better to change the term itself. We here offer physicians the possibility to refer to this condition as unresponsive wakefulness syndrome or UWS. As this neutral descriptive term indicates, it refers to patients showing a number of clinical signs (hence syndrome) of unresponsiveness (that is, without response to commands) in the presence of wakefulness (that is, eye opening).

Differential time and related appearance of signs, indicating improvement in the state of consciousness in vegetative state traumatic brain injury (VS-TBI) patients after initiation of dopamine treatment.

OBJECTIVE: The goal of the study was to look for the response of treatment with increasing doses of dopaminergic medication on the recovery of vegetative state patients post-TBI. DESIGN: A prospective study of eight patients aged 25-50 years in vegetative state (VS) of mean duration of 104 days following traumatic brain injury (TBI) was performed by investigating changes of their state of consciousness while they were treated with levodopa/carbidopa. RESULTS: Initial improvement was observed in all patients within a mean of 13 days after onset of treatment. Seven patients recovered consciousness after a mean time of 31 days of treatment. The remaining patient showed only slight improvement to minimally conscious state. The sequence of symptoms leading to recovery was the same in all patients; the first to appear was moving a limb on a request, which appeared at a mean time of 13 days. Gradual increase of dose leads to the appearance of better-organized responses like reacting to more than one command, than opening the mouth and appearance of a reciprocal contact. The only side effect was visual hallucinations in one patient, which disappeared after decreasing the dosage. CONCLUSIONS: Clinical awareness to the structured order of responses and to the effect of dosage can help clinicians in early assessment of response to dopaminergic treatment in VS patients.

Loewenstein communication scale for the minimally responsive patient.

PRIMARY OBJECTIVE: Any sign of communicative ability in patients in vegetative state can provide information about regain of consciousness and conservation of cognitive abilities. The aim of this study was to test the reliability and validity of an instrument designed to measure the degree of communication in minimally responsive patients. MATERIALS: The Loewenstein Communication Scale (LCS) measures five hierarchical functions - mobility, respiration, visual responsiveness, auditory comprehension and linguistic skills (verbal or alternative) - which are divided into five parameters and rated in developmental order on a 5-point scale by level of difficulty. Scores for each function are summed to obtain a quantitative communication profile. METHODS: Forty-two adult patients in vegetative state, as a result of acquired brain injury, were examined with the proposed LCS for the minimally responsive patients by two speech and language clinicians at admission to the Intensive Care Unit (ICU) for brain injured patients and, thereafter, at least once weekly. At the end of the ICU stay, 27 patients who showed signs of recovery and were referred for continued rehabilitation were compared to a group of 15 patients who were not referred for continued rehabilitation, for functional and general LCS scores. The predictive power of the LCS in differentiating between these groups was tested. RESULTS: The LCS was found to have very good reliability with good inter-rater agreement. Patients who eventually continued rehabilitation had significantly higher total scores as well as in the motor, visual and auditory sub-scales. Logistic regression results indicated that these parameters successfully differentiated between the two groups of patients, even after adjusting for age and for scores on the Glasgow Coma Scale. CONCLUSION: The LCS for the minimally responsive patients proved to be reliable and predictive of rehabilitation progress of minimally responsive patients. It may be useful for the interdisciplinary rehabilitation team in planning early individually targeted therapeutic programmes.