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Characterize the temporal profile of recovery of communication after severe brain injury.Retrospective cohort study.Inpatient rehabilitation hospital.Patients with severe acquired brain injury and no evidence of communication on the Coma Recovery Scale-Revised (CRS-R) (N=175).Time from injury to recovery of intentional communication (IC, inconsistent yes/no responses) and functional communication (FC, consistent and accurate yes/no responses) on the CRS-R Communication subscale.Patients (N=175) were included in the primary observation period of the first 8 weeks of inpatient rehabilitation (median [interquartile range, IQR]: 48 [27-61] years old, 105 men, 28 [21-38] days postinjury, 100 traumatic etiology). Fifty-four patients (31%) did not recover IC or FC. Thirty patients (17%) recovered IC only (median [IQR] days from injury to IC= 40 [34-54]), 72 patients (41%) recovered IC followed by FC (days from injury to FC=50 [42-61]), and 19 patients (11%) recovered FC without first recovering IC (43 [32-63]). The patients who recovered neither IC nor FC within 8 weeks of admission were admitted to rehabilitation later than those who recovered IC and/or FC (P.01). Sixteen patients who did not recover communication within 8 weeks of admission to rehabilitation subsequently recovered FC prior to discharge.In patients with severe brain injury receiving inpatient rehabilitation, discernible yes-no responses emerged approximately 6 weeks postinjury and became reliable 1 week later. Approximately 1 in 3 patients did not demonstrate IC or FC within 8 weeks of admission to rehabilitation, although 33% of these individuals recovered communication prior to discharge. In total, 61% of patients recovered FC prior to discharge from rehabilitation.

Background 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. Objectives We aimed to determine the feasibility of a single session of transcranial direct current stimulations (tDCS) to reduce spasticity in chronic patients with DOC. Methods 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. Results 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. Conclusion 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.

Resume Les progres de la medecine et des soins intensifs ont conduit a une augmentation du nombre de patients survivant a une lesion cerebrale severe. Bien que certains patients recuperent rapidement, d’autres demeurent dans un etat de conscience alteree (ECA). Ces derniers peuvent evoluer du coma vers un etat vegetatif/syndrome d’eveil non repondant (EV/ENR), puis vers un etat de conscience minimale (ECM). Dans cette revue, nous proposons tout d’abord de decrire les differentes methodes, comportementales et de neuro-imagerie, utilisees dans le diagnostic des patients en ECA. Nous decrirons ensuite les facteurs susceptibles d’influencer le pronostic et la recuperation de ces patients, ainsi que les traitements et la prise en charge qui peuvent etre proposes dans le but d’ameliorer leur etat de conscience. Enfin, nous cloturerons cette revue avec une reflexion sur les considerations ethiques et les questions de fin de vie.

Transcranial direct current stimulation (tDCS) applied over the dorsolateral prefrontal cortex (DLPFC) has induced promising behavioral improvement, both in acute and chronic minimally conscious state (MCS - [ 1 ]) patients [ 2 , 3 ]. We previously defined a tDCS-responder as a patient who demonstrates a new sign of consciousness following stimulation, which was neither present beforehand, nor before or after the sham stimulation [ 2 ]. In a study investigating the metabolic and structural differences between DLPFC-tDCS-responders and non-responders, we have identified that tDCS-responders presented a preservation of brain metabolism and grey matter integrity under the stimulated area, but also in the thalamus and the precuneus, areas involved in consciousness recovery [ 4 ]. Even if these results provided relevant insights into potential biomarkers of responsiveness, the access to such neuroimaging techniques (positron emission tomography - PET - and magnetic resonance imaging - MRI) remains limited. Recently, it has been demonstrated that high-density electroencephalography (hdEEG) network metrics in the alpha band correlates with the level of consciousness [ 5 ]. In addition, a strong correlation between brain metabolism and hdEEG network metrics was reported, making this bedside assessment a robust way to evaluate patients’ brain function.

The present report shows the case of a patient who came with the diagnosis of UWS and who was then diagnosed as being in MCS minus following repeated standardized behavioral assessments. Neuroimaging data further suggested that the patient presented preservation of brain activity closer to what is usually observed in healthy subjects.The presence of a minimal sign of consciousness (i.e., localization to noxious stimuli) was only observed once out of seven behavioral assessments, and active tasks using fMRI and EEG suggested the presence of covert command-following. During this week of assessments, overt response to command was never observed at the patient's bedside. This behavior was solely seen following the experimental procedure of tDCS, after which the patient could reproducibly answer a simple behavioral command. Based on these findings, we hypothesize that tDCS may facilitate motor execution of the command when cognitive functions are preserved in patients with cognitive-motor dissociation.

Introduction/Background Spasticity is a common complication after a severe brain injury that hinders the rehabilitative process, reduces the patients’ quality of life and is frequently responsible of pain (Thibaut et al., 2015). Here, we investigate in a population of patients with disorders of consciousness the correlation between spasticity and pain during mobilization to better characterize the spastic profiles that are more prone to induce pain. Material and method In this cross-sectional study 73 patients with chronic (>3 months post insult) disorders of consciousness were included [27 women; mean age: 40 ± 13 y; 42 with traumatic etiology; 50 in minimally conscious state (MCS) and 23 in unresponsive wakefulness syndrome (UWS)]. We evaluated the pain with the Nociceptive Coma Scale-Revised (NCS-R) and the spasticity with the Modified Ashworth Scale (MAS). Results Out of 73 patients, 70 demonstrated signs of spasticity (96%; MAS ≥ 1), including 52 who showed severe spasticity (71%; MAS ≥ 4 at least in one joint; 35 in MCS and 17 in UWS). Moreover, 13 patients in MCS (26%) and 5 in UWS (22%) showed severe pain during mobilization (NCS-R ≥ 4 at least in one joint). Moreover, we found a strong correlation with the Spearman's rank correlation indicator between pain during mobilization and the spasticity of the wrist's and fingers’ flexors and hip's adductors (respectively ρ=0.254, P = 0.03; ρ=0.269, P = 0.02; ρ=0.277, P = 0.02), while the correlation was weaker for biceps, knee's and ankle's flexors (respectively ρ=0.195, P = 0.1; ρ=0.176, P = 0.14; ρ=0.115, P = 0.36). Conclusion We confirm the high prevalence of spasticity and pain in patients with disorders of consciousness and the correlation between the degrees of spasticity and pain scores. We found that the peripheral joints of the upper limbs and the hip adductors are more prone to induce pain. These data highlight the need to prevent the onset of spasticity and the importance of the treatment of pain in patients with disorders of consciousness.

Objectives To assess the effects of frontoparietal transcranial direct current stimulation (tDCS) in patients with disorders of consciousness using the Coma Recovery Scale-Revised (CRS-R) in a randomized double blind sham controlled cross-over study. Methods This study was performed on patients in unresponsive wakefulness syndrome (UWS), minimal conscious state (MCS), and emergence of MCS (EMCS). We enrolled 15 patients (UWS = 7, MCS = 7, EMCS = 1; average age = 44.6 ± 14.4; 7 traumatic patients and 8 non-traumatic). Two session of tDCS were delivered, using either anodal or sham stimulation in a randomized order. Frontoparietal areas were stimulated using a current of 1 mA during 20 min. Consciousness was assessed with the CRS-R before and after each stimulation. Results A tendency of improvement was observed after the real tDCS session ( p = 0.075) while no significant change was found after the sham session ( p = 0.205). It was noticed that a higher percentage (43%) of patients in MCS increased their CRS-R score after an actual tDCS; compared to only 14% of patients in UWS. Conclusion Some improvements were observed further to tDCS stimulations. Based on a larger sample of patients, the positive effect of frontoparietal tDCS could become more significant. This stimulation technique could, in a near future, prove its utility in MCS patients’ rehabilitation.

Ces dernieres annees, grâce au perfectionnement des techniques de reanimation, le nombre de patients survivant a leur lesion cerebrale a fortement augmente. Tandis que certains se retablissent rapidement, d’autres traversent differents etats de conscience alteree (coma, etat vegetatif/non repondant ou etat de conscience minimale) avant de recuperer ou non un etat de conscience normal. Les patients en etat de conscience alteree representent un probleme majeur tant au niveau diagnostique, pronostique, therapeutique, qu’au niveau de leur prise en charge quotidienne. Diverses possibilites de traitements pharmacologiques et non pharmacologiques ont ete etudiees. Les techniques des stimulations transcrâniennes a courant continu (tDCS) augmentent l’excitabilite corticale et le flux sanguin cerebral regional. La plasticite cerebrale s’en voit amelioree, ce qui module l’activite corticale et donc l’activite fonctionnelle des aires se trouvant sous l’anode. Une plasticite cerebrale est parfois encore possible, meme au stade chronique. Un des problemes majeurs de ces patients est la spasticite qui cause diverses complications (retractions musculaires, subluxations et luxations articulaires, escarres, positions vicieuses) en plus du facteur algique. Ces complications sont d’autant plus importantes que ces patients sont voues a rester alites. La kinesitherapie permet de reduire les complications liees a la spasticite mais est parfois insuffisante et la prise d’antispastiques est inevitable. La technique la plus couramment utilisee est l’etirement passif : son efficacite dans la reduction des phenomenes spastiques est clairement reconnue. Par ailleurs, des etudes ont montre l’interet de la mise en place d’une attele souple au niveau du membre superieur chez les patients spastiques. L’avantage de cette technique est sa simplicite d’utilisation. Cette attelle se base sur le principe de saturation du systeme proprioceptif cutane a l’aide d’un tissu elastique, ceci simultanement a un reequilibrage des antagonistes. De nombreuses pistes restent encore a explorer pour une prise en charge optimale des patients cerebroleses.