Positive effects of music therapist's selected auditory stimulation on the autonomic nervous system of patients with disorder of consciousness: a randomized controlled trial

The current randomized controlled trial was performed at the China Rehabilitation Science Institute, China to test the hypothesis that musical auditory stimulation has positive effects on the autonomic nervous system of patients with disorder of consciousness.Although past studies have recommended that patients with disorder of consciousness listen to patient-preferred music, this practice is not universally accepted by researchers.Twenty patients with severe disorder of consciousness listened to either therapist-selected(n = 10, 6 males and 4 females;43.33 ± 18.76 years old) or patient-preferred(n = 10, 5 males and 5 females, 48.83 ± 18.79 years old) musical therapy, 30 minutes/day, 5 times/week for 6 weeks.The results showed no obvious differences in heart rate variability-related parameters including heart rate, standard deviation of normal-to-normal R-R intervals, and the root-mean-square of successive heartbeat interval differences of successive heartbeat intervals between the two groups of patients.However, percentage of differences exceeding 50 ms between adjacent normal number of intervals, low-frequency power/high-frequency power, high-frequency power norm, low-frequency power norm, and total power were higher in patients receiving therapist-selected music than in patients receiving their own preferred music.In contrast, this relationship was reversed for the high-frequency power and very-low-frequency band.These results suggest that compared with preferred musical stimulation, therapist-selected musical stimulation resulted in higher interactive activity of the autonomic nervous system.Therefore, therapist-selected musical stimulation should be used to arouse the autonomic nervous system of patients with disorder of consciousness.This study was approved by the Institutional Ethics Committee of China Rehabilitation Research Center, China(approval No.2018-022-1) on March 12, 2018 and registered with the Chinese Clinical Trial Registry(registration number Chi CTR1800017809) on August 15, 2018.

Recovery from prolonged disorders of consciousness:A dual-center prospective cohort study in China

BACKGROUND Recent innovations in intensive care have improved the prognosis of patients with severe brain injuries and brought more patients with disorders of consciousness(DoC).Data are lacking regarding the long-term outcomes of those patients in China.It is necessary to study the long-term outcomes of patients with prolonged DoC in light of many factors likely to influence crucial decisions about their care and their life.AIM To present the preliminary results of a DoC cohort.METHODS This was a two-center prospective cohort study of inpatients with vegetative state(VS)/unresponsive wakefulness syndrome(UWS).The study outcomes were the recovery from VS/UWS to minimally conscious state(MCS)and the long-term status of patients with prolonged DoC considered in VS/UWS or MCS for up to 6 years.The patients were evaluated using the Glasgow coma scale,coma recovery scale-revised,and Glasgow outcome scale.The endpoint of follow-up was recovery of full consciousness or death.The changes in the primary clinical outcome improvement in clinical diagnosis were evaluated at 12 mo compared with baseline.RESULTS The study population included 93 patients(62 VS/UWS and 31 MCS).The postinjury interval range was 28-634 d.Median follow-up was 20 mo(interquartile range,12-37 mo).At the endpoint,33 transitioned to an emergence from MCS or full consciousness,eight had a locked-in syndrome,and there were 35 patients remaining in a VS/UWS and 11 in an MCS.Seven(including one locked-in syndrome)patients(7.5%)died within 12 mo of injury.Compared with the unresponsive group(n=52)at 12 mo,the responsive group(n=41)had a higher proportion of males(87.8%vs 63.5%,P=0.008),shorter time from injury(median,40.0 d vs 65.5 d,P=0.006),higher frequency of vascular etiology(68.3%vs 38.5%,P=0.007),higher Glasgow coma scale score at admission(median,9 vs 6,P<0.001),higher coma recovery scale-revised score at admission(median,9 vs 2.5,P<0.001),at 1 mo(median,14 vs 5,P<0.001),and at 3 mo(median,20 vs 6,P<0.001),lower frequency of VS/UWS(36.6%vs 90.0%,P<0.001),and more favorable Glasgow outcome scale outcome(P<0.001).CONCLUSION Patients with severe DoC,despite having strong predictors of poor prognosis,might recover consciousness after a prolonged time of rehabilitation.An accurate initial diagnosis of patients with DoC is critical for predicting outcome and a long-term regular follow-up is also important.

Cognitive Neurobiology of Consciousness and Memory during Anesthesia Awareness—Scientific Possibilities and Clinical Implications

The condition of pharmacologically induced unconsciousness that renders a patient unresponsive to uncomfortable surgical stimuli is known as general anesthesia. When it is used for surgery, a fairly rare but traumatizing state known as anesthesia awareness might develop. What is the probability that a patient can be awake, conscious, and able to hear the surroundings and experience excruciating pain but be immobilized to communicate it during surgery? According to estimates, there are 1 to 2 cases for every 1000 patients who experience this phenomenon and retain various sensory information after general anesthesia was applied. Even with seemingly effective anesthetic care, emerging consciousness states during anesthesia are reported and often come with various degrees of memory loss mechanisms. Some researchers and the experiments covered in this paper suggest anesthesia is merely a memory loss or poorly understood neurological form of amnesia induced during the event itself and not a loss of consciousness per se during the traumatic event, as suggested by studies described in this article. In some instances, the agony may be unbearable, with long-term neuropsychiatric effects such as post-traumatic stress disorder. Although the neurobiological phenomenon of consciousness regained during anesthesia is still poorly understood, these continuously reported events carry significant medical and legal ramifications. The numerous contributing elements that may increase the risk of intraoperative raised levels of consciousness are gathered, analyzed, and discussed in this research study. Preventive methods for both preinduction and intraoperative usage, as well as corrective actions to take after such occurrences, are also discussed.

Clinical Decision on Disorders of Consciousness After Acquired Brain Injury:Stepping Forward

Major advances have been made over the past few decades in identifying and managing disorders of consciousness(DOC)in patients with acquired brain injury(ABI),bringing the transformation from a conceptualized definition to a complex clinical scenario worthy of scientific exploration.Given the continuously-evolving framework of precision medicine that integrates valuable behavioral assessment tools,sophisticated neuroimaging,and electrophysiological techniques,a considerably higher diagnostic accuracy rate of DOC may now be reached.During the treatment of patients with DOC,a variety of intervention methods are available,including amantadine and transcranial direct current stimulation,which have both provided class II evidence,zolpidem,which is also of high quality,and non-invasive stimulation,which appears to be more encouraging than pharmacological therapy.However,heterogeneity is profoundly ingrained in study designs,and only rare schemes have been recommended by authoritative institutions.There is still a lack of an effective clinical protocol for managing patients with DOC following ABI.To advance future clinical studies on DOC,we present a comprehensive review of the progress in clinical identification and management as well as some challenges in the pathophysiology of DOC.We propose a preliminary clinical decision protocol,which could serve as an ideal reference tool for many medical institutions.

Transcutaneous auricular vague nerve stimulation improved brain connection activity on patients of disorders of consciousness: a pilot study

OBJECTIVE:To evaluate the clinical effect of transcutaneous auricular vagus nerve nerve stimulation(ta VNS)on disorders of consciousness(DOC)patients with Coma Recovery Scale-Revised(CRS-R)and cerebral cortex activity by electroencephalogram(EEG)detection.METHODS:Randomized controlled methods were used to evaluate the clinical effect of ta VNS on patients with DOC.Twelve patients with initial CRS-R of 6-10 were randomly divided into the treatment group of ta VNS and control group of transcutaneous non-auricular vague nerve stimulation(tn VNS).According to clinical diagnosis,the treatment group was divided into vegetative state(VS)group and minimally conscious state(MCS)group.RESULTS:The energy of delta and beta bands is positively correlated with the brain activity of patients.ta VNS has different regulatory effects on patients with different conscious States.In ta VNS group,the energy of delta band in local brain regions changed significantly.Significant changes in brain connection activity were limited to local brain regions.While in patients with MCS in the ta VNS group,delta and beta band energy significantly changed in multiple brain regions and crossbrain connection activity also changed significantly.CONCLUSION:These findings suggest that ta VNS may be a related extra method for arousing patients’awakening by improving brain connection activity.And the effect is remarkable in MCS patients.

Neuromodulatory therapies for patients with prolonged disorders of consciousness

Background:Reviving patients with prolonged disorders of consciousness(DOCs)has always been focused and challenging in medical research.Owing to the limited effectiveness of available medicine,recent research has increasingly turned towards neuromodulatory therapies,involving the stimulation of neural circuits.We summarised the progression of research regarding neuromodulatory therapies in the field of DOCs,compared the differences among different studies,in an attempt to explore optimal stimulation patterns and parameters,and analyzed the major limitations of the relevant studies to facilitate future research.Methods:We performed a search in the PubMed database,using the concepts of DOCs and neuromodulation.Inclusion criteria were:articles in English,published after 2002,and reporting clinical trials of neuromodulatory therapies in human patients with DOCs.Results:Overall,187 published articles met the search criteria,and 60 articles met the inclusion criteria.There are differences among these studies regarding the clinical efficacies of neurostimulation techniques for patients with DOCs,and large-sample studies are still lacking.Conclusions:Neuromodulatory techniques were used as trial therapies for DOCs wherein their curative effects were controversial.The difficulties in detecting residual consciousness,the confounding effect between the natural course of the disease and therapeutic effect,and the heterogeneity across patients are the major limitations.Large-sample,well-designed studies,and innovations for both treatment and assessment are anticipated in future research.

Consciousness and speech evaluation of 96 patients with craniocerebral injury

Objective: To explore the effective methods for evaluating the consciousness and speech status of patients with special types of cerebral injuries.Methods: Atotal of 96 patients with injury in the language center and in coma were treated with operative and correlated conventional therapies. Then their recovery status of consciousness and speech was observed.Results: All the patients were recovered to consciousness. Sixty-nine patients with aphasia were cured completely, but 7 patients were complicated with incomplete ataxic aphasia, 15 with incomplete sensory aphasia,and 5 with incomplete mixed aphasia.Conclusions: For the patients with injury in the language center, evaluation of the conscious state with GCS scoring system has certain limitations and conscious behaviours are advantageous evidences to evaluate the consciousness recovery of the patients. The patients with conscious disturbance and injury in the language center should be considered to have aphasia.

Neuroimage-Based Consciousness Evaluation of Patients with Secondary Doubtful Hydrocephalus Before and After Lumbar Drainage

Hydrocephalus is often treated with a cerebrospinal fluid shunt(CFS) for excessive amounts of cerebrospinal fluid in the brain.However,it is very difficult to distinguish whether the ventricular enlargement is due to hydrocephalus or other causes,such as brain atrophy after brain damage and surgery.The non-trivial evaluation of the consciousness level,along with a continuous drainage test of the lumbar cistern is thus clinically important before the decision for CFS is made.We studied 32 secondary mild hydrocephalus patients with different consciousness levels,who received T1 and diffusion tensor imaging magnetic resonance scans before and after lumbar cerebrospinal fluid drainage.We applied a novel machine-learning method to find the most discriminative features from the multi-modal neuroimages.Then,we built a regression model to regress the JFK Coma Recovery Scale-Revised(CRS-R) scores to quantify the level of consciousness.The experimental results showed that our method not only approximated the CRS-R scores but also tracked the temporal changes in individual patients.The regression model has high potential for the evaluation of consciousness in clinical practice.

Clinical application of Chinese Nanjing persistent vegetative state scale

Background:It is a challenge to characterize the consciousness level of patients with severe disturbance of consciousness and predict their prognosis effectively for Chinese doctors.We aimed to investigate the psychometric property and the diagnostic practicality of severe disturbance of consciousness by Chinese Nanjing persistent vegetative state scale(CNPVSS)which was first set up in 1996 and modified in 2001 and 2011.Methods:The concurrent validity,inter-rater consistency and diagnostic accuracy of CNPVSS and Chinese version of coma recovery scale-revised(CRS-R)were investigated by assessment of 380 patients with severe disorders of consciousness.Results:Total scores of the CNPVSS were correlated significantly with that of the CRS-R,indicating acceptable concurrent validity.Sub-scale analysis showed moderate to high inter-rater reliability and test-retest reliability.CNPVSS was superior to CRS-R on the diagnosis sensitivity.The CNPVSS was able to distinguish 65 patients in emergence from minimal consciousness state who were misclassified as in minimal consciousness state(MCS)by the CRS-R,and it could also distinguish two patients in MCS who were misclassified as in vegetative state by the CRS-R.Conclusion:The CNPVSS is an appropriate measurement and is sensitive to distinguish the MCS patients from the VS patients.

Risk factors for brain injury in patients with exertional heatstroke:A 5-year experience

Purpose:Minimal data exist on brain injury in patients with exertional heatstroke(EHS)in developing country.In this study,we explored the risk factors for brain injury induced by EHS 90-day after onset.Methods:A retrospective cohort study of patients with EHS was conducted in the intensive care unit of the General Hospital of Southern Theater Command of PLA in China from April 2014 to June 2019.Patients were divided into non-brain injury(fully recovered)and brain injury groups(comprising deceased patients or those with neurological sequelae).The brain injury group was further subdivided into a death group and a sequela group for detailed analysis.General information,neurological performance and information on important organ injuries in the acute stage were recorded and analysed.Multivariable logistic regression was used to identify risk factors for brain injury after EHS and mortality risk factors for brain injury,and Kaplan-Meier survival curve was used to evaluate the effect of the neurological dysfunction on survival.Results:Out of the 147 EHS patients,117 were enrolled,of which 96(82.1%)recovered,13(11.1%)died,and 8(6.8%)experienced neurological sequelae.Statistically significant differences were found between non-brain injury and brain injury groups in age,hypotension,duration of consciousness disorders,time to drop core body temperature below 38.5℃,lymphocyte counts,platelet counts,procalcitonin,alanine aminotransferase,aspartate aminotransferase,creatinine,cystatin C,coagulation parameters,international normalized ratio,acute physiology and chronic health evaluation II scores,sequential organ failure assessment(SOFA)scores,and Glasgow coma scale scores(all p<0.05).Multivariate logistic regression showed that age(OR=1.090,95%CI:1.02-1.17,p=0.008),time to drop core temperature(OR=8.223,95%CI:2.30-29.40,p=0.001),and SOFA scores(OR=1.676,95%CI:1.29-2.18,p<0.001)are independent risk factors for brain injury induced by EHS.The Kaplan-Meier curves suggest significantly prolonged survival(p<0.001)in patients with early Glasgow coma scale score>8 and duration of consciousness disorders≤24 h.Conclusions:Advanced age,delayed cooling,and higher SOFA scores significantly increase the risk of brain injury post-EHS.These findings underscore the importance of rapid cooling and early assessment of organ failure to improve outcomes in EHS patients.