Early and goal-directed management of complications and comorbidities is imperative to facilitate neurorecovery and to optimize outcomes of disorders of consciousness (DoC). This is the first large retrospective cohort study on the primary medical and neurological complications and comorbidities in persons with DoC. A total of 146 patients admitted to a specialized inpatient DoC rehabilitation program from 1 January 2014 to 31 October 2018 were included. The incidences of those conditions since their initial brain injuries were reviewed per documentation. They were categorized into reversible causes of DoC, confounders and mimics, and other medical/neurological conditions. The common complications and comorbidities included pneumonia (73.3%), pain (75.3%), pressure ulcers (70.5%), oral and limb apraxia (67.1%), urinary tract infection (69.2%), and 4-limb spasticity (52.7%). Reversible causes of DoC occurred very commonly. Conditions that may confound the diagnosis of DoC occurred at surprisingly high rates. Conditions that may be a source of pain occurred not infrequently. Among those that may diminish or confound the level of consciousness, 4.8 ± 2.0 conditions were identified per patient. In conclusion, high rates of various complications and comorbidities occurred in persons with DoC. Correcting reversible causes, identifying confounders and mimics, and managing general consequences need to be seriously considered in clinical practice.

This is a retrospective study to investigate the results of using zolpidem and lorazepam in persons with disorders of consciousness (DoC) and to provide practical information for clinical application and further studies. The cohort included 146 patients (11 hemorrhagic stroke, 87 traumatic brain injury (TBI), 48 anoxic brain injury (ABI)) admitted to a specialized DoC rehabilitation program. A positive trial indicated a patient responded to either zolpidem or lorazepam with prominent functional improvements necessitating routine use of the medication. Non-responders had equivocal or negative (i.e., went to sleep) responses. Eleven patients with a stroke who had either medication were all non-responders. Of the remaining 135 patients, 95 received at least one medication trial. The overall positive rate was 11.6% (11/95), with 6.3% (5/79) for zolpidem and 14.0% (6/43) for lorazepam. Among TBI patients, the positive rate of the zolpidem trial (10.2%, 5/49) was slightly higher than that of the lorazepam trial (6.9%, 2/29; p > 0.05). Among ABI patients, the positive rate of the lorazepam trial (28.6%, 4/14) was significantly higher than that of the zolpidem trial (0%, 0/30; p = 0.007). Following a positive trial, most patients were continued on the medications on a regular basis before eventual discontinuation. Our results suggested the etiology of DoC, considering traumatic vs. anoxic injuries, may serve in guiding the clinical application of these medications in the treatment of DoC and in future prospective studies. We advocate for screening all patients with DoC using zolpidem and/or lorazepam.

Background: Disorders of consciousness (DoCs) after severe brain injury are considered to be conditions with dire prognosis. Despite the accumulating evidence, inpatient rehabilitation is often denied by payers referring to the Medicare/Medicaid criteria, under the assumption that such patients will not “actively” participate in therapy or make “measurable improvements.”Objective: This study aimed to report on the effectiveness and efficiency of a specialized inpatient DoC rehabilitation program based on measurable clinical parameters.Methods: A retrospective cohort study was conducted. The cohort comprised 137 patients with DoC admitted to a specialized acute inpatient rehabilitation program between January 2014 and October 2018. Patients were categorized as having been admitted at the acute stage (<=28 days post-injury), subacute stage (29–365 days following a traumatic brain injury (TBI) or 29–90 days following a non-TBI), or chronic stage (>365 days following a TBI or >90 days following a non-TBI). Outcomes included changes in level of consciousness (based on the Coma Recovery Scale–Revised (CRS-R), while also acknowledging scenarios beyond those captured by the CRS-R via Individualized Qualitative Behavioral Assessment and team consensus); Functional Independence Measure (FIM) levels; achievements in decannulation and initiation of oral diet; and time to those achievements.Results: The rates of emergence from a minimally conscious state were 90, 62, and 18% among patients admitted at the acute, subacute, and chronic stages, respectively. Among patients who emerged, 100, 85, and 67%, respectively, had measurable FIM scores. Approximately 60 and 20% of patients at the acute and subacute stages, respectively, required moderate assistance or less in transfer/communication/eating/grooming/upper body dressing by the time of discharge from Phase I admission. The decannulation rates were 94, 67, and 17%. The oral diet initiation rates were 70, 23, and 6%. The time to reach these achievements lengthened as chronicity increased. There was a weak positive correlation (r_s = 0.308) in the case of decannulation and a strong positive correlation (r_s = 0.606, both p < 0.01) in the case of oral diet between days since injury on admission and days to the achievement after admission. Patients with TBI and hypoxic brain injury had comparable recovery rates when admitted at the acute and subacute stages.Conclusion: Specialized intensive inpatient rehabilitation is crucial and time-sensitive for functional recovery from DoC caused by TBI and hypoxic–ischemic brain injury. Specific goals and different outcome measures need to be developed to appraise the benefits of acute inpatient rehabilitation for DoC.

The study investigated the impact of patient positioning on behavioral assessment of consciousness in individuals with a disorder of consciousness (DoC) using the Coma Recovery Scale-Revised (CRS-R). In this retrospective study, 1,470 CRS-R assessments were performed on 232 patients in four different positions: lying in bed (Bed), sitting at edge of mat (Mat), sitting in a wheelchair (Wheelchair), and standing (Standing), in an acute inpatient rehabilitation setting. A conditional random coefficients multi-level model was used to examine changes in the transformed CRS–R total unit (which converted the raw CRS-R total score to an equal-interval scale) across positions, accounting for repeated measurements within subjects and variability introduced by different raters. Transformed CRS–R total unit was significantly associated with assessment position. Compared to the Bed position (controlling age, gender, etiology, number of arousal protocol used, and days post-injury), patients assessed in the Wheelchair, Mat, and Standing positions had estimated 2.7-, 3.2-, and 3.5-unit increases in the transformed CRS–R total unit (p = 0.02, 0.01, and 0.11), respectively. Number of arousal protocols used was not significantly associated with assessment position. Increased use of these protocols did not enhance CRS–R performance. Improved physical and cognitive functionality in an upright position, rather than arousal alone, may contribute to the improvements on the CRS-R. Our results revealed that patients scored higher on the CRS-R in an upright position compared to a lying position. This suggests that the CRS-R is better performed in an upright position instead of a lying position in patients with DoC. We recommend assessing the level of consciousness in patients with DoC in an upright position and out of bed whenever feasible.

Owing to major progress in the survivorship following acquired brain injury (ABI), there exists a pressing need for the development of systems of care and rehabilitation tailored to ABI. One of the supportive systems is brain injury resource facilitation (brain injury RF), which focuses on having therapeutic, social, and financial resources readily available and easily accessible for persons with ABI. Brain injury RF comprises identification of a person’s strengths and challenges, goal setting, resource identification, coordination, access, utilization, monitoring, evaluation, and advocacy. Brain injury RF is critically important in bridging community services for persons with ABI and eliminating disjointed approaches of care that fail to address the full range of the individual’s needs and long-term success. Over recent years, multiple stakeholders in the field of ABI have worked to develop and implement strategies for timely brain injury RF. This white paper aims to provide an overview of the current status of brain injury RF and an analysis on the challenges and opportunities in brain injury RF for ABI. Practical policy recommendations for its implementation are proposed to the potential funders of brain injury RF programs at the national, state, and community levels. We call for attention to this pressing need in society and advocate for a novel, pragmatic, and culturally informed approach in the development of brain injury RF in communities where people with ABI reside.