Poster 57: Persistent Vegetative State: New Approaches in Complex Treatment

Abstract

Setting: Not provided. Patients: 15 patients with a diagnosed vegetative condition were observed and treated. The level of consciousness, according to Glasgow Coma Scale (GCS), was 7 to 9 points. The reasons for the comas that led to the vegetative state were craniocerebral trauma in 9 cases and cerebral stroke in 6 cases. Case Descriptions: All patients had complete evaluations, including neurovisualization (computed tomography, magnetic resonance tomography of the brain), defining the parameters of brain blood flow (transcranial Doppler), electroencephalography, study of brain-evoked potentials (somatosensory, cognitive), transcranial magnetic stimulation, and neuropsychologic testing. For 2 to 3 months, patients received complex rehabilitation (eg, medical treatment, kinesiotherapy, massage, verticalization, selective vibrostimulation of feet in the regime of cyclogram of walking, programmed electrostimulation, logopedic exercises). According to the GCS, patients’ levels increased by 1 to 2 points. In the following 2 months, to basic rehabilitation, we added walking training on the Lokomat system and monitored hemodynamic indices. The Lokomat allows one to reproduce normal walking as closely as possible by using biomechanic indices and contributes to the formation of complex polysystematic synchronized reactions of the organism. The inclusive criteria for each patient were readiness for walking, training for the ability to keep systolic pressure between 80 and 90mmHg, and to keep diastolic blood pressure not lower than 50mmHg for 7 to 10 minutes in the vertical position on the verticalizator. Training was held 5 times a week, for 10 to 20 minutes, the course 10 to 20 procedures. Prime speed was 1.5km/h; maximum speed was 2km/h. Assessment/Results: There was an increase in the level of the consciousness (GCS, minimally conscious state [MCS]): in 3 patients with craniocerebral insult at the end of the fourth month of observation, we noticed signs of “the condition of little consciousness” (according to the MCS) in the form of prolonged fixation, stable reaction of eyes, stable behavioral reactions on the corresponding polymodal stimuli, and the level of consciousness, which increased up to 12 to 13 points. 2 patients with craniocerebral trauma had the locked-in syndrome. 4 patients with craniocerebral trauma improved to the level of psycho-organic syndrome (15 points). 1 stroke patient after the fourth month improved to the level of akinetic mutism, with speech understanding (11 points). 3 patients from the stroke group at the end of the fifth month also showed an increase in consciousness, up 12 to 14 points and, according to the MCS, up to the “condition of little consciousness.” 1 patient from the stroke group showed no change in rehabilitation status during treatment. Discussion: There was improvement of posutral control (restoration of the correct position and increase of the strength of spine, neck and shoulder muscles). The spasticity decrease (measured by the Ashworth Scale) allowed for an increase in movement amplitudes of the lower-extremity joints. Hemodynamic indices stabilized. The amplitude of the sensory component (peak 2) in the investigation of cognitive indices increased. Conclusions: The inclusion of robotic training for walking allowed patients with stroke and craniocerebral trauma to increase their levels of consciousness. This method should be tested in further clinical investigations.