Practice guideline update recommendations summary: Disorders of consciousness: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology; the American Congress of Rehabilitation Medicine; and the National Institute on Disability, Independent Living, and Rehabilitation Research

OBJECTIVETo update the 1995 American Academy of Neurology (AAN) practice parameter on persistent vegetative state and the 2002 case definition on minimally conscious state (MCS) and provide care recommendations for patients with prolonged disorders of consciousness (DoC). METHODSRecommendations were...

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Published in:	Neurology Vol. 91; no. 10; pp. 450 - 460
Main Authors:	Giacino, Joseph T, Katz, Douglas I, Schiff, Nicholas D, Whyte, John, Ashman, Eric J, Ashwal, Stephen, Barbano, Richard, Hammond, Flora M, Laureys, Steven, Ling, Geoffrey S.F, Nakase-Richardson, Risa, Seel, Ronald T, Yablon, Stuart, Getchius, Thomas S.D, Gronseth, Gary S, Armstrong, Melissa J
Format:	Journal Article
Language:	English
Published:	United States American Academy of Neurology 04-09-2018 Lippincott Williams & Wilkins
Subjects:	Consciousness Disorders - rehabilitation Humans Neurology - methods Neurology - organization & administration Physical and Rehabilitation Medicine - standards Practice Guidelines as Topic - standards Rehabilitation Research - methods Rehabilitation Research - organization & administration Special United States United States
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Summary:	OBJECTIVETo update the 1995 American Academy of Neurology (AAN) practice parameter on persistent vegetative state and the 2002 case definition on minimally conscious state (MCS) and provide care recommendations for patients with prolonged disorders of consciousness (DoC). METHODSRecommendations were based on systematic review evidence, related evidence, care principles, and inferences using a modified Delphi consensus process according to the AAN 2011 process manual, as amended. RECOMMENDATIONSClinicians should identify and treat confounding conditions, optimize arousal, and perform serial standardized assessments to improve diagnostic accuracy in adults and children with prolonged DoC (Level B). Clinicians should counsel families that for adults, MCS (vs vegetative state [VS]/unresponsive wakefulness syndrome [UWS]) and traumatic (vs nontraumatic) etiology are associated with more favorable outcomes (Level B). When prognosis is poor, long-term care must be discussed (Level A), acknowledging that prognosis is not universally poor (Level B). Structural MRI, SPECT, and the Coma Recovery Scale–Revised can assist prognostication in adults (Level B); no tests are shown to improve prognostic accuracy in children. Pain always should be assessed and treated (Level B) and evidence supporting treatment approaches discussed (Level B). Clinicians should prescribe amantadine (100–200 mg bid) for adults with traumatic VS/UWS or MCS (4–16 weeks post injury) to hasten functional recovery and reduce disability early in recovery (Level B). Family counseling concerning children should acknowledge that natural history of recovery, prognosis, and treatment are not established (Level B). Recent evidence indicates that the term chronic VS/UWS should replace permanent VS, with duration specified (Level B). Additional recommendations are included.
Bibliography:	ObjectType-Article-1 SourceType-Scholarly Journals-1 ObjectType-Feature-2 ObjectType-Review-3 content type line 23 This research was supported through a memorandum of understanding between the American Academy of Neurology, the American Congress of Rehabilitation Medicine, and the National Institute on Disability and Rehabilitation Research (NIDRR). In 2014, NIDRR was moved from the US Department of Education to the Administration for Community Living of the US Department of Health and Human Services, and was renamed the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR). This article does not reflect the official policy or opinions of NIDILRR or HHS and does not constitute an endorsement by NIDILRR, HHS, or other components of the federal government. Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article. This practice guideline was endorsed by the American Academy of Physical Medicine and Rehabilitation on April 4, 2018; by the American College of Surgeons Committee on Trauma on July 3, 2018; and by the Child Neurology Society on April 17, 2018. This special article is published simultaneously in the Archives of Physical Medical Rehabilitation and Neurology. Neurology was responsible for peer review of this article. Approved by the AAN Guideline Development, Dissemination, and Implementation Subcommittee on October 21, 2017; by the AAN Practice Committee on April 9, 2018; by the American Congress of Rehabilitation Medicine Board of Governors on April 30, 2018; by the National Institute on Disability, Independent Living, and Rehabilitation Research Review Committee on April 5, 2018; and by the AAN Institute Board of Directors on May 2, 2018.
ISSN:	0028-3878 1526-632X 1526-632X
DOI:	10.1212/WNL.0000000000005926