Theses Doctoral

The Effect of Early Rehabilitation and Multimodal Stimulation on Recovery in Patients with Disorders of Consciousness and Cognitive Motor Dissociation

Casertano, Lorenzo Oscar

Purpose/Statement of Problem: Disorders of Consciousness (DoC) are a group of disorders encompassing Coma, Unresponsive Wakefulness Syndrome (UWS), and Minimally Conscious State. These disorders are characterized by altered or absent alertness and consciousness and inability to follow commands or participate in daily activities or function. DoC can be caused by a multitude of etiologies including trauma, stroke, tumors, metabolic disarray, and many others. Individuals with severe DoC are profoundly functionally and cognitively impaired, and frequently require extensive rehabilitation in order to return to their prior level of function.

Additionally, a category has recently been discovered within the umbrella of DoC called Cognitive Motor Dissociation (CMD), in which individuals may show no outward signs of the ability to follow commands but can be seen to respond appropriately to commands when monitored by Electroencephalography (EEG). The current standard of rehabilitative care for individuals with severe DoC is minimal. There are no clear guidelines for rehabilitation of these individuals, particularly in the acute stage. Rehabilitation is often initiated once individuals are awake and able to follow commands, despite evidence that earlier intervention (particularly in the form of stimulation) may accelerate recovery.

In this retrospective study, we had three primary aims and one case study. The first aim was to characterize the time frame in which a cohort of individuals with severe DoC received therapy and whether the timeframe in which they received therapy was appropriate. The second aim was to retrospectively determine which therapy and demographics factors could predict better short- and long-term outcomes. The third aim was to determine whether the presence of CMD had a mediating effect on therapy. Finally, the case study was intended to determine safety of a prospective study recruiting individuals extremely early after admission for a standardized stimulation intervention.

Procedures and Methods: This study was a retrospective analysis of data from a cohort of individuals who were recruited to participate in multiple studies of consciousness in the neurological intensive care unit (NICU) in an academic medical center in New York City between 2014 and 2021, heretofore referred to as the parent study. All individuals had a severe DoC, were connected to EEG, had no previous history of brain injury, and were tested for presence of CMD. Charts were examined to determine whether individuals could have received therapy earlier. Regression modeling was used to determine the effect of various therapy factors (such as timing, volume, frequency, and therapy content) as well as demographics data on a variety of short term and long-term outcome measures. These outcome measures included scores on the Coma Recovery Scale-Revised, scores on the AM-PAC “6 Clicks” Basic Mobility and Daily Activity short forms, recovery of active participation in therapy, discharge destination, and Glasgow Outcomes Scale-Extended scores. Analyses were also performed on the individual effect of each therapy variable on the effect of CMD status, and on the overall effect of CMD status on outcomes.

Results: Thirty-eight of the fifty eight (65.52%) individuals in this cohort who received therapy after the median day received for the cohort could have safely received therapy earlier in the form of a standardized stimulation protocol. Multiple therapy variables were implicated in both short- and long-term outcomes. More specifically, therapy frequency, therapy volume, CMD status, sitting at edge of bed, and age were all implicated in both short- and long-term outcomes. Therapy timing was not an independent predictor for any outcomes but was significantly associated with therapy frequency. Therapy frequency was an independent predictor of multiple outcomes including discharge destination, Basic Mobility scores, and GOS-E scores. Sitting at the edge of the bed was an independent predictor of Daily Activity Score, and all therapy variables except timing were independent predictors of change in Basic Mobility Score. CMD status had a modulatory effect on multiple therapy variables (variable based on outcome) and was an independent predictor of long-term outcomes.

Conclusions: Individuals with severe DoC were an underserved population from a therapy perspective. With the current standard of care, individuals with severe DoC frequently overlooked in favor of those who are more able to participate in active therapy. Analyses performed in this study indicated that individuals with severe DoC could a.) safely receive therapy sooner, b.) benefit from increased therapy frequency and specific modes of therapy, c.) could make excellent functional progress and d.) might have performed better with therapy if they had CMD. These results indicate that individuals with severe DoC might benefit earlier and more consistent therapy to maximize their chances of functional recovery.

Geographic Areas


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More About This Work

Academic Units
Biobehavioral Sciences
Thesis Advisors
Rao, Ashwini K.
Ed.D., Teachers College, Columbia University
Published Here
May 22, 2024