Clinical trial NCT05954650: Clinical Validity of the Minimally Conscious State "Plus" and "Minus"
Official title: Minimally Conscious State Plus Versus Minus: Likelihood of Emergence and Long-term Functional Independence
Study type: OBSERVATIONAL
Overall status: COMPLETED
Conditions: Disorder of Consciousness
Keywords: Disorders of Consciousness
Minimally Conscious State
Minimally Conscious State Plus
Minimally Conscious State Minus
Disability Rating Scale
Functional Independence
Lead sponsor: Hospitales Nisa
Sponsor class: OTHER
Collaborators: name: Generalitat Valenciana
First posted: 2023-07-20
Enrollment: 80
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Observational model: COHORT
Time perspective: RETROSPECTIVE
Sampling method: NON_PROBABILITY_SAMPLE
Study population: Data of patients with DOC who had attended an inpatient neurorehabilitation program between January 2004 and December 2022 in all facilities of the hospital network.

Brief summary: The goal of this observational retrospective study is to investigate and compare the clinical evolution of a sample of patients with the diagnosis of MCS+ versus MCS- according to the CRS-R. The main questions it aims to answer are the presence of differences in the likelihood of emergence from the MCS (EMCS) between these two groups and in the progress of disability and functional independence after the EMCS.

Detailed description: Severe acquired brain injuries can be caused by traumatic brain injury, stroke or anoxia, among others and can lead to Disorders of Consciousness (DOC), an umbrella term that encompasses a wide range of different clinical conditions such as coma, the Unresponsive Wakefulness Syndrome (UWS) and the Minimally Conscious State (MCS). Coma usually lasts from a few days to few weeks and it is defined as a state of profound unawareness from which the patient cannot be aroused; eyes are closed, and a normal sleep-wake cycle is absent. The UWS denotes a condition of wakefulness without (clinical signs of) awareness; UWS patients may open their eyes but exhibit only reflex (i.e. non-intentional) behaviors and are therefore considered unaware of themselves and their surroundings. On the other hand, the MCS denotes a condition where discernible behavioral evidence of consciousness is retained. More recently, given the heterogeneity of the MCS category, patients showing higher level responses, including reproducible movements to commands, intelligible verbalization and intentional communication (i.e. MCS+), have been distinguished from those showing lower level non-reflex responses (e.g. visual pursuit, object recognition; i.e. MCS-). Once patients recovery the ability to communicate or to use objects they are considered emerged from the MCS (EMCS).

Currently, the gold standard for the behavioural assessment of DOC patients is the Coma Recovery Scale-Revised (CRS-R) and the diagnosis is made according to the presence of certain behaviours. However, because of daily fluctuations, a minimum of 5 CRS-R evaluations within a short time interval are recommended, allowing to reduce the risk of misdiagnose to the 40%.

If the CRS-R criteria for the diagnosis of coma and UWS are somehow clear, the MCS and EMCS entities are the focus of a growing body of research. Despite all, the diagnostic criteria for DOC patients are becoming clearer and clearer, but markers to predict prognosis and functional outcome need to be better studied. Knowing the natural history of patients with DOC may help to an adequate prognosis, that is important not only for the patient and the family but also for treatment planning and provision of therapies and discharge. In particular, if there are existing studies about the prognosis of UWS and MCS patients, studies comparing MCS- and MCS+ patients are lacking. State of the art about the prognosis in DOC patients highlight a better outcome for patients in a MCS compared to patients in UWS, but little is known about a possible different prognosis between MCS+ and MCS- patients. A recent study stresses the need for prospective studies investigating differences in long-term functional outcome between patients in a MCS+ and MCS-. So far, the only available longitudinal study including MCS- and MCS+ patients followed 39 chronic DOC patient for two years after brain injury and assessed them with the CRS-R every 3 months. The sample included 16 patients in a UWS, 15 patients in a MCS-, 7 in a MCS+ and 1 in a EMCS and the authors did not find differences in the prognosis between MCS- and MCS+ patients, probably due to limited sample size.

Therefore, the first aim of this study is to investigate and compare the clinical evolution of a sample of patients with the diagnosis of MCS+ versus MCS- according to the CRS-R total score. In particular, the investigators focus our attention on the likelihood of emergence from the MCS and on the evolution of functional independence after the emergence from the MCS. The investigators hypothesize that those patients presenting preferentially complex behavioural responses will have better clinical trajectories including an increasing likelihood to emerge form MCS and a better functional outcome once emerged from the MCS.

Eligibility criteria: Inclusion Criteria:

* Severe acquired brain injury leading to a Disorder of Consciousness (DOC)
* Persistance of the DOC for a period not inferior to 28 days and not longer than 6 months
* Diagnosis of MCS
* Having a fa follow-up period of no less than 12 months from the onset

Exclusion Criteria:

* Diagnosis of UWS
* Being younger than 18 years
* DOC persisting more than 6 months
* Absence of follow-up

Primary outcomes:
measure: Baseline clinical state
timeFrame: At admission to the rehabilitation hospital
measure: Baseline neurobehavioral condition
timeFrame: At admission to the rehabilitation hospital
measure: Baseline disability
timeFrame: At the admission to the rehabilitation hospital
measure: Progress in the clinical state
timeFrame: Weekly assessments from admission to the rehabilitation hospital to discharge, demise, or emergence from MCS, up to 36 months
measure: Progress in the neurobehavioral condition
timeFrame: Weekly assessments from admission to the rehabilitation hospital to discharge, demise, or emergence from MCS, up to 36 months
measure: Progress in disability
timeFrame: Monthly assessments from admission to the rehabilitation hospital to discharge, demise, or emergence from MCS, up to 36 months
measure: Follow-up disability
timeFrame: At 6 months after emergence from MCS
measure: Follow-up independence in activities of daily living
timeFrame: At 6 months after emergence from MCS
measure: Follow-up functional Independence
timeFrame: At 6 months after emergence from MCS
Secondary outcomes:
Other outcomes:
Locations:
city: Valencia
country: Spain
facility: Hospitales NISA
city: Valencia
country: Spain
facility: Servicio de Neurorrehabilitación y Daño Cerebral de los Hospitales NISA
Study officials:
References:
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