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• A survey of people in China thought that life-sustaining treatment should not be stopped in individuals with chronic locked-in syndrome. Especially neurologists thought that it might also be unnecessary to withdraw life-sustaining treatment because the locked-in syndrome is not terminal or irreversible. • The survey did not identify a dissociation between personal preferences and general opinions, possibly because of a social uniformity in China where individualism is less pronounced. • Families experience the stress of caring for individuals with locked-in syndrome. The quality-of-life score was lower for relatives than non-relatives. Locked-in syndrome (LIS) characterizes individuals who have experienced pontine lesions, who have limited motor output but with preserved cognitive abilities. Despite their severe physical impairment, individuals with LIS self-profess a higher quality of life than generally expected. Such third-person expectations about LIS are shaped by personal and cultural factors in western countries. We sought to investigate whether such opinions are further influenced by the cultural background in East Asia. We surveyed attitudes about the ethics of life-sustaining treatment in LIS in a cohort of medical and non-medical Chinese participants. The final study sample included 1545 respondents: medical professionals (n = 597, 39%), neurologists (n = 303, 20%), legal professionals (n = 276, 18%) and other professionals (n = 369, 24%), including 180 family members of individuals with LIS. Most of the participants (70%), especially neurologists, thought that life-sustaining treatment could not be stopped in individuals with LIS. It might be unnecessary to withdraw life-sustaining treatment, because the condition involved is not terminal and irreversible, and physical treatment can be beneficial for the patient. A significant proportion (59%) of respondents would like to be kept alive if they were in that condition; however, older people thought the opposite. Families experience the stress of caring for individuals with LIS. The mean (SD) quality of life score for relatives was 0.73 (2.889) (on a −5, +5 scale), which was significantly lower than that of non-relatives, 1.75 (1.969) (P < 0.001). Differences in opinions about end of life in LIS are affected by personal characteristics. The current survey did not identify a dissociation between personal preferences and general opinions, potentially because of a social uniformity in China where individualism is less pronounced. Future open-ended surveys could identify specific needs of caregivers so that strategic interventions to reduce ethical debasement are designed. [ABSTRACT FROM AUTHOR]

• The adaptation of a brain-computer interface (BCI) application may be optimized by the user-centered design approach. • Effectiveness, efficiency and satisfaction are the 3 main aspects to be evaluated. • The perceived workload of a BCI task affects patient performance. • Mood, motivation and quality of life are also important aspects in BCI performance. People who survive severe brain damage may eventually develop a prolonged consciousness disorder. Others can regain full consciousness but remain unable to speak or move because of the severity of the lesions, as for those with locked-in syndrome (LIS). Brain-computer interface techniques can be useful to disentangle these states by detecting neurophysiological correlates of conscious processing of information to enable communication with these individuals after the diagnosis. The goal of our study was to evaluate with a user-centered design approach the usability of a mental imagery task to detect signs of voluntary information processing and enabling communication in a group of severely disabled individuals. Five individuals with LIS participated in the study. Participants were instructed to imagine hand, arm or feet movements during electroencephalography (EEG) to detect patterns of event-related synchronization/desynchronization associated with each task. After the user-centered design, usability was evaluated (i.e., efficiency, effectiveness and satisfaction). Two participants achieved significant levels of accuracy in 2 different tasks. The associated workload and levels of satisfaction perceived by the users were moderate and were mainly related to the time demand of the task. Results showed lack of effectiveness of the task to detect voluntary brain activity and thus detect consciousness or communicate with non-responsive individuals. The application must be modified to be sufficiently satisfying for the intended end-users and suggestions are made in this regard. [ABSTRACT FROM AUTHOR]

• More than two thirds of individuals with disorders of consciousness (DOC) present spastic muscle overactivity (SMO). • Management of SMO in DOC patients is a challenge. • Transcranial direct-current stimulation (tDCS) of the primary motor cortex (M1) has reduced SMO in individuals with stroke. • M1 tDCS in a small sample of individuals with DOC showed promise to reduce SMO. Spasticity management in severely brain-injured patients with disorders of consciousness (DOC) is a major challenge because it leads to complications and severe pain that can seriously affect quality of life. We aimed to determine the feasibility of a single session of transcranial direct current stimulations (tDCS) to reduce spasticity in chronic patients with DOC. We enrolled 14 patients in this double-blind, sham-controlled randomized crossover pilot study. Two cathodes were placed over the left and right primary motor cortex and 2 anodes over the left and right prefrontal cortex. Hypertonia of the upper limbs and level of consciousness were assessed by the Modified Ashworth Scale (MAS) and the Coma Recovery Scale-Revised (CRS-R). Resting state electroencephalography was also performed. At the group level, spasticity was reduced in only finger flexors. Four responders (29%) showed reduced hypertonicity in at least 2 joints after active but not sham stimulation. We found no behavioural changes by the CRS-R total score. At the group level, connectivity values in beta2 were higher with active versus sham stimulation. Relative power in the theta band and connectivity in the beta band were higher for responders than non-responders after the active stimulation. This pilot study highlights the potential benefit of using tDCS for reducing upper-limb hypertonia in patients with chronic DOC. Large-sample clinical trials are needed to optimize and validate the technique. [ABSTRACT FROM AUTHOR]

• The diagnostic of disorders of consciousness is challenging but crucial. • The SECONDs is a quick behavioral tool for assessing consciousness. • The scale is easy to use in brain-injured patients in daily routine clinical practice. • It has good reliability and validity as compared with the most recommended scale. The Coma Recovery Scale-Revised (CRS-R) is the gold standard to assess severely brain-injured patients with prolonged disorders of consciousness (DoC). However, the amount of time needed to complete this examination may limit its use in clinical settings. Objective. We aimed to validate a new faster tool to assess consciousness in individuals with DoC. This prospective validation study introduces the Simplified Evaluation of CONsciousness Disorders (SECONDs), a tool composed of 8 items: arousal, localization to pain, visual fixation, visual pursuit, oriented behaviors, command-following, and communication (both intentional and functional). A total of 57 individuals with DoC were assessed on 2 consecutive days by 3 blinded examiners: one CRS-R and one SECONDs were performed on 1 day, whereas 2 SECONDs were performed on the other day. A Mann-Whitney U test was used to compare the duration of administration of the SECONDs versus the CRS-R, and weighted Fleiss' kappa coefficients were used to assess inter-/intra-rater reliability as well as concurrent validity. In the 57 participants, the SECONDs was about 2.5 times faster to administer than the CRS-R. The comparison of the CRS-R versus the SECONDs on the same day or the best of the 3 SECONDs led to "substantial" or "almost perfect" agreement (kappa coefficients ranging from 0.78 to 0.85). Intra-/inter-rater reliability also showed almost perfect agreement (kappa coefficients from 0.85 to 0.91 and 0.82 to 0.85, respectively). The SECONDs appears to be a fast, reliable and easy-to-use scale to diagnose DoC and may be a good alternative to other scales in clinical settings where time constraints preclude a more thorough assessment. [ABSTRACT FROM AUTHOR]

• 99% of patients with disorders of consciousness present at least one swallowing disorder. • A tracheostomy, cough reflex and efficacy of the oral phase of swallowing are the three criteria related to consciousness. • Unresponsive wakefulness syndrome patients and minimally conscious patients differ in spontaneous saliva management. • None of the minimally conscious patients receive ordinary oral food. • The efficacy of the oral phase of swallowing may be a sign of consciousness. After a period of coma, a proportion of individuals with severe brain injury remain in an altered state of consciousness before regaining partial or complete recovery. Individuals with disorders of consciousness (DOC) classically receive hydration and nutrition through an enteral-feeding tube. However, the real impact of the level of consciousness on an individual's swallowing ability remains poorly investigated. We aimed to document the incidence and characteristics of dysphagia in DOC individuals and to evaluate the link between different components of swallowing and the level of consciousness. We analyzed clinical data on the respiratory status, oral feeding and otolaryngologic examination of swallowing in DOC individuals. We analyzed the association of components of swallowing and participant groups (i.e., unresponsive wakefulness syndrome [UWS] and minimally conscious state [MCS]). We included 92 individuals with DOC (26 UWS and 66 MCS). Overall, 99% of the participants showed deficits in the oral and/or pharyngeal phase of swallowing. As compared with the MCS group, the UWS group more frequently had a tracheostomy (69% vs 24%), with diminished cough reflex (27% vs 54%) and no effective oral phase (0% vs 21%). Almost all DOC participants had severe dysphagia. Some components of swallowing (i.e., tracheostomy, cough reflex and efficacy of the oral phase of swallowing) were related to consciousness. In particular, no UWS participant had an efficient oral phase, which suggests that its presence may be a sign of consciousness. In addition, no UWS participant could be fed entirely orally, whereas no MCS participant orally received ordinary food. Our study also confirms that objective swallowing assessment can be successfully completed in DOC individuals and that specific care is needed to treat severe dysphagia in DOC. [ABSTRACT FROM AUTHOR]