sign130

9.1.2 MINIMALLy CONSCIOUS STATE
A patient can be considered to be functioning in the MCS if there is clear evidence of being able to perform
one or more of the following behaviours: 156
y follow simple commands
y demonstrate gestural or verbal yes/no responses (regardless of accuracy)
y verbalise intelligibly
y demonstrate purposeful behaviour, including movements or affective behaviours which are contingent
upon environmental stimuli (eg appropriate smiling/crying, visual tracking object, vocalised/gestural
response appropriate to questions or instruction).
A patient can be considered to have emerged from the MCS when they are able to reliably and consistently
demonstrate one or both of the following:
y functional interactive communication (eg verbal/gestural yes/no responses to questions, or written
questions)
y functional use of two different objects.
A wide range of medical, surgical, pharmacological, environmental and sensory stimulation intervention
techniques has been used with patients in states of disordered consciousness. Many published studies have
reported outcomes with single cases or a small case series. There are very few group designs reported in the
literature and a lack of control data for comparative purposes.
9.2 ASSESSING CHANGES IN CoNSCIouS lEVEl
One systematic review evaluated the evidence for assessment scales to measure disorders of consciousness
and concluded that the Coma Recovery Scale – Revised (CRS-R) can be used with minor reservations due to
unproven criterion validity. 158 The Sensory Modality and Rehabilitation Technique, Western Neuro Sensory
Stimulation Profile, Sensory Stimulation Assessment Measure, Wessex Head Injury Matrix and Disorders
of Consciousness Scale may be used with moderate reservations due to limited evidence of reliability or
criterion validity.
A systematic review of individual cases investigated the use of functional imaging techniques (eg positron
emission tomography, functional magnetic resonance imaging) with patients in the vegetative state and
concluded that evidence of ‘higher level’ cortical activation in response to complex, personally salient auditory
stimuli can provide important information regarding residual brain function and prognosis. However, the
available literature was noted to be sparse, with unblinded and uncontrolled studies using a wide range of
different assessment and intervention procedures.
B The Coma Recovery Scale - Revised should be used to assess patients in states of disordered
consciousness.
Given the challenges associated with assessing patients with disorders of consciousness, it is important
that clinicians should have training in administering disorders of consciousness assessment tools and
also an appreciation of the range of assessment tools available for use with this population.
9.3 PHARMAColoGICAl THERAPy
9 • Management of the patient in the minimally conscious or vegetative state
One systematic review of mostly single case series evaluated pharmacological interventions for patients
in the VS or MCS. 159 The authors found some supporting evidence for the use of dopaminergic agents
(levodopa and amantadine) to improve conscious level with a very small number of patients (n=6). There
was also some evidence to support the use of the hypnotic agent zolpidem (n=21), however conflicting
treatment effects were seen across patients with only a small proportion showing a clear benefit (n=7). The
authors report the results of a small series of patients (n=5) treated with intrathecal baclofen for spasticity
who also demonstrated associated improvements in conscious level. Considerable limitations were noted
within the literature, including a lack of cohort or blinded and controlled study designs, a lack of consistency
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