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      Neurorehabilitation of Traumatic Brain Injury (TBI): A Clinical Review

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          Abstract

          Traumatic brain injury (TBI) and its potential long-term consequences are of major concern for public health. Neurorehabilitation of affected individuals has some specific characteristics in contrast to neurorehabilitation of patients with acquired brain lesions of other aetiology. This review will deal with the clinical consequences of the distinct lesions of TBI. In severe TBI, clinical course often follows a typical initial sequence of coma; followed by disturbed consciousness; later, post-traumatic agitation and amnesia; and finally, recovery of function occurs. In the different phases of neurorehabilitation, physicians should be aware of typical medical complications such as paroxysmal sympathetic hyperactivity, posttraumatic hydrocephalus, and posttraumatic neuroendocrine dysfunctions. Furthermore, we address questions on timing and on existing evidence for different rehabilitation programmes and for holistic neuropsychological rehabilitation approaches.

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          Most cited references88

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          The JFK Coma Recovery Scale-Revised: measurement characteristics and diagnostic utility.

          To determine the measurement properties and diagnostic utility of the JFK Coma Recovery Scale-Revised (CRS-R). Analysis of interrater and test-retest reliability, internal consistency, concurrent validity, and diagnostic accuracy. Acute inpatient brain injury rehabilitation hospital. Convenience sample of 80 patients with severe acquired brain injury admitted to an inpatient Coma Intervention Program with a diagnosis of either vegetative state (VS) or minimally conscious state (MCS). Not applicable. The CRS-R, the JFK Coma Recovery Scale (CRS), and the Disability Rating Scale (DRS). Interrater and test-retest reliability were high for CRS-R total scores. Subscale analysis showed moderate to high interrater and test-retest agreement although systematic differences in scoring were noted on the visual and oromotor/verbal subscales. CRS-R total scores correlated significantly with total scores on the CRS and DRS indicating acceptable concurrent validity. The CRS-R was able to distinguish 10 patients in an MCS who were otherwise misclassified as in a VS by the DRS. The CRS-R can be administered reliably by trained examiners and repeated measurements yield stable estimates of patient status. CRS-R subscale scores demonstrated good agreement across raters and ratings but should be used cautiously because some scores were underrepresented in the current study. The CRS-R appears capable of differentiating patients in an MCS from those in a VS.
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            Unresponsive wakefulness syndrome: a new name for the vegetative state or apallic syndrome

            Background Some patients awaken from coma (that is, open the eyes) but remain unresponsive (that is, only showing reflex movements without response to command). This syndrome has been coined vegetative state. We here present a new name for this challenging neurological condition: unresponsive wakefulness syndrome (abbreviated UWS). Discussion Many clinicians feel uncomfortable when referring to patients as vegetative. Indeed, to most of the lay public and media vegetative state has a pejorative connotation and seems inappropriately to refer to these patients as being vegetable-like. Some political and religious groups have hence felt the need to emphasize these vulnerable patients' rights as human beings. Moreover, since its first description over 35 years ago, an increasing number of functional neuroimaging and cognitive evoked potential studies have shown that physicians should be cautious to make strong claims about awareness in some patients without behavioral responses to command. Given these concerns regarding the negative associations intrinsic to the term vegetative state as well as the diagnostic errors and their potential effect on the treatment and care for these patients (who sometimes never recover behavioral signs of consciousness but often recover to what was recently coined a minimally conscious state) we here propose to replace the name. Conclusion Since after 35 years the medical community has been unsuccessful in changing the pejorative image associated with the words vegetative state, we think it would be better to change the term itself. We here offer physicians the possibility to refer to this condition as unresponsive wakefulness syndrome or UWS. As this neutral descriptive term indicates, it refers to patients showing a number of clinical signs (hence syndrome) of unresponsiveness (that is, without response to commands) in the presence of wakefulness (that is, eye opening).
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              Evidence-based cognitive rehabilitation: updated review of the literature from 2003 through 2008.

              To update our clinical recommendations for cognitive rehabilitation of people with traumatic brain injury (TBI) and stroke, based on a systematic review of the literature from 2003 through 2008. PubMed and Infotrieve literature searches were conducted using the terms attention, awareness, cognitive, communication, executive, language, memory, perception, problem solving, and/or reasoning combined with each of the following terms: rehabilitation, remediation, and training for articles published between 2003 and 2008. The task force initially identified citations for 198 published articles. One hundred forty-one articles were selected for inclusion after our initial screening. Twenty-nine studies were excluded after further detailed review. Excluded articles included 4 descriptive studies without data, 6 nontreatment studies, 7 experimental manipulations, 6 reviews, 1 single case study not related to TBI or stroke, 2 articles where the intervention was provided to caretakers, 1 article redacted by the journal, and 2 reanalyses of prior publications. We fully reviewed and evaluated 112 studies. Articles were assigned to 1 of 6 categories reflecting the primary area of intervention: attention; vision and visuospatial functioning; language and communication skills; memory; executive functioning, problem solving and awareness; and comprehensive-holistic cognitive rehabilitation. Articles were abstracted and levels of evidence determined using specific criteria. Of the 112 studies, 14 were rated as class I, 5 as class Ia, 11 as class II, and 82 as class III. Evidence within each area of intervention was synthesized and recommendations for Practice Standards, Practice Guidelines, and Practice Options were made. There is substantial evidence to support interventions for attention, memory, social communication skills, executive function, and for comprehensive-holistic neuropsychologic rehabilitation after TBI. Evidence supports visuospatial rehabilitation after right hemisphere stroke, and interventions for aphasia and apraxia after left hemisphere stroke. Together with our prior reviews, we have evaluated a total of 370 interventions, including 65 class I or Ia studies. There is now sufficient information to support evidence-based protocols and implement empirically-supported treatments for cognitive disability after TBI and stroke. Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.
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                Author and article information

                Journal
                Med Sci (Basel)
                Med Sci (Basel)
                medsci
                Medical Sciences
                MDPI
                2076-3271
                18 March 2019
                March 2019
                : 7
                : 3
                : 47
                Affiliations
                [1 ]Department of Neurology, University Neurorehabilitation, Inselspital Bern, Bern University Hospital and University of Bern, 3010 Bern, Switzerland; rene.mueri@ 123456dbmr.unibe.ch
                [2 ]ARTORG Center for Biomedical Engineering Research, University of Bern, 3010 Bern, Switzerland
                Author notes
                Author information
                https://orcid.org/0000-0001-6990-4188
                Article
                medsci-07-00047
                10.3390/medsci7030047
                6473767
                30889900
                a7531bcd-dacd-4c9e-b549-dd8bd6710a25
                © 2019 by the authors.

                Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( http://creativecommons.org/licenses/by/4.0/).

                History
                : 20 December 2018
                : 08 March 2019
                Categories
                Review

                traumatic brain injury,neurorehabilitation,disorders of consciousness,paroxysmal sympathetic hyperactivity,posttraumatic agitation,posttraumatic hydrocephalus,posttraumatic neuroendocrine disorders,cognitive rehabilitation,neuropsychological rehabilitation

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