Date Presented 03/28/20
We report rehabilitation interventions delivered to facilitate recovery of consciousness for patients with a traumatic brain injury. Interventions reported may prompt OT practitioners to seek advanced training in preparatory stimulation methods. The results of this review identify gaps in the literature, specifically the content of OT treatment.
Primary Author and Speaker: Jennifer Weaver
Additional Authors and Speakers: Kristen Maisano, Alison Cogan, Trudy Mallinson
Contributing Authors: Sophie Leeds, Ann Guernon, Kelsey Watters, Jennifer Nebel, Theresa Bender Pape
PURPOSE: Occupational therapy practitioners report “trying things” when selecting interventions to facilitate recovery of consciousness for patients with a traumatic brain injury (TBI). The 2018 practice guidelines for disorders of consciousness recommend rehabilitation services. We aim to identify rehabilitation interventions utilized to facilitate recovery of consciousness for patients following a TBI.
DESIGN: We conducted a PRISMA systematic review of rehabilitation interventions to facilitate recovery of consciousness following a TBI. Our search strategy was developed with a research librarian to include terms related to: recovery of consciousness, activities of daily living, traumatic brain injury, and disorders of consciousness. We searched Cochrane, Embase, PsycInfo, Scopus, and PubMed for articles from 2015-2019. Study inclusion criteria included: English language, one adult (>18 years) with disorders of consciousness following a TBI, includes treatment/interventions addressing recovery of consciousness.
METHOD: Two authors conducted the title, abstract, and full text review. Once the article met all eligibility criteria, data was extracted, and a methodological assessment was conducted using the Scottish Intercollegiate Guidelines Network. A content analysis explored the rehabilitation intervention concepts in the included articles.
RESULTS: We screened 3,851 articles and 31 met inclusion criteria. Of the 31 articles, 13 were randomized control trials, six non-randomized control trials, three case control studies, three cohort studies, and six case series. Case series are not assessed for methodological rigor; of the 25 studies evaluated the majority (n=20, 80%) had an acceptable rating while two studies were unacceptable, one study was low quality, and two studies were rated the highest (high quality). Content analysis identified rehabilitation interventions as either multi-disciplinary or specific. Multi-disciplinary interventions described what was provided to the patient (e.g. positioning, environmental stimulation, disciplines caring for the patients, Snoezelen, etc.) but did not provide sufficient details to enable replication. The specific interventions were categorized as preparatory, positioning, and sensory. Preparatory interventions include transcranial direct current stimulation (tDCS), repetitive transcranial magnetic stimulation (rTMS), and median nerve stimulation. Positioning interventions included a tilt table, positioning in bed and/or wheelchair, and a verticalization program in the intensive care unit. Sensory stimulation included music, familiar voice, and specific protocols. Surprisingly, over half of the articles utilized preparatory interventions.
CONCLUSION: Identifying the rehabilitation interventions to facilitate recovery of consciousness for patients in disordered states of consciousness following a brain injury outlines therapeutic treatments as well as the treatment gaps in the literature. The most often reported interventions were preparatory (e.g. rTMS, tDCS, etc), yet it is unknown how frequently this occurs in clinical practice. The majority of the articles about preparatory interventions lacked a linkage to function identifying an opportunity for occupational therapy. The multi-disciplinary studies were more general in the description of OT services. Identifying the specific content of OT treatment will promote our value on the interdisciplinary care team.
IMPACT STATEMENT: We provide the beginning of a critical conversation ensuring OT practitioners are posited with the evidence for rehabilitation interventions facilitating recovery of consciousness specific to patients following a brain injury.
References
Guernon, A., Papadimitriou, C., Walsh, E., Weaver, J., Pape, T. B., & Mallinson, T. (2018). Clinical Reasoning when Treating Patients with Disorders of Consciousness Following Severe Traumatic Brain Injury. Arch Phys Med Rehabil, 99(11), e131. doi:https://doi.org/10.1016/j.apmr.2018.08.011
Giacino, J. T., Katz, D. I., Schiff, N. D., Whyte, J., Ashman, E. J., Ashwal, S., . . . Armstrong, M. J. (2018). Practice Guideline Update Recommendations Summary: Disorders of Consciousness: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology; the American Congress of Rehabilitation Medicine; and the National Institute on Disability, Independent Living, and Rehabilitation Research. Arch Phys Med Rehabil, 99(9). doi:10.1016/j.apmr.2018.07.001
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