Intensive physiotherapy for vegetative and minimally conscious state patients: a retrospective audit and analysis of therapy intervention

Abstract

Purpose: To analyse physiotherapy interventions and evaluate their effectiveness in the prevention and management of contracture with patients admitted in either vegetative or minimally conscious state in a UK Inpatient Regional Acquired Brain Injury Rehabilitation Service. Method: Retrospective audit of dependency levels and physiotherapy interventions in ten vegetative or minimally conscious state patients admitted over a 3-year period (2006–2009). Admission and discharge patient dependency status, Wessex Head Injury Matrix data and passive range of movement measurements on admission and discharge from physiotherapy were recorded. Results: All patients presented with hypertonicity including contractures and all initially received a manual stretching/passive movement programme. Casting/splinting was employed in 8 cases and 7 received botulinum toxin injections. Standing regimes were initiated for 8 patients. No patient emerged out of either vegetative or minimally conscious state. Although they remained fully dependent for care needs, carer burden was reduced and all patients were able sustain a seating regimen. No minimal clinically important difference was observed in 85 out of 120 joint ranges measured (70.8%). Positive outcomes were observed in only 14 joints (11.7%) and negative outcomes in 21 joints (17.5%). Conclusion: At present, there is a paucity of evidence regarding physiotherapy efficacy to inform the management of patients in vegetative or minimally conscious state. Clearer agreed definitions of clinically important difference in passive range of movement are required to allow better interpretation of outcomes. Interventions should be aimed at minimising carer burden and developing individualised disability management programmes. Further research documenting the long-term outcomes in such patients is warranted.Implications for RehabilitationAmong patients in low awareness states, there is a paucity of evidence for routine daily/weekly passive movement or standing regimes on a continuing long-term basis.Clearer agreed definitions of contracture, clinically important difference, and hypertonicity are required to help therapists identify and interpret significant change and thereby ensure efficacy of individualised disability management programmes with this patient group.Intensive physiotherapy provided to patients in vegetative or minimally conscious states can be withdrawn when an optimum positioning, seating and care handling programme can be sustained.