Abstract
Objective: To detect the initiation of swallowing in patients with disorders of consciousness (DOC) as well as the relationship between the initiation of swallowing and the prognosis of DOC patients.Methods: Nineteen DOC patients were included in this study, and a self-controlled trial compared five different stimuli. The five different stimuli were as follows: (1) one command, as recommended by the Coma Recovery Scale-Revised (CRS-R), which was “open your mouth”; (2) placing a spoon in front of the patient's mouth without a command; (3) placing a spoon filled with water in front of the patient's mouth without a command; (4) one command—“there is a spoon; open your mouth”—with a spoon in front of the patient's mouth; (5) one command, “there is a spoon with water; open your mouth,” with a spoon filled with water in front of the patient's mouth. All 19 patients were given these five stimuli randomly, and any one of the commands was presented four times to a patient, one at a time, at 15-s intervals. The sensitivity and specificity of the initiation of swallowing in detecting conscious awareness were determined.Results: None of the patients responded to the first four stimuli. However, six patients showed initiated swallowing toward the fifth stimulus. Among those six, five patients showed improvement in their consciousness state 6 months later. The sensitivity and specificity of the initiation of swallowing for DOC patients was 83.33% [95% CIs (36%, 100%)] and 92.31% [95% CIs (64%, 100%)], respectively.Conclusions: The initiation of swallowing can be an early indication of conscious behavior and can likely provide evidence of conscious awareness.Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03508336; Date of registration: 2018/4/16.
Highlights
Disorders of consciousness (DOC) include several states, ranging from coma and unresponsive wakefulness syndrome/vegetative state (UWS/VS) to a minimally conscious state (MCS) [1]
The initiation of swallowing can be an early indication of conscious behavior and can likely provide evidence of conscious awareness
It shows that none of the MCS− and UWS patients responded to the first four stimuli; six DOC patients initiated swallowing toward the fifth stimulus
Summary
Disorders of consciousness (DOC) include several states, ranging from coma and unresponsive wakefulness syndrome/vegetative state (UWS/VS) to a minimally conscious state (MCS) [1]. UWS/VS patients show no sign of consciousness of either themselves or the environment [2]. The clinically heterogeneous MCS patients were subcategorized into two distinct entities: “MCS minus” (MCS−) and “MCS plus” (MCS+) [4, 5]. MCS− patients showed low-level purposeful behaviors without command following (e.g., visual pursuit, localization to noxious stimulation, object localization [reaching], automatic motor response, and appropriate smiling or crying related to an external stimuli). MCS plus (MCS+) patients were those who presented higher-level behavioral interactions (e.g., a movement in response to a command, nonfunctioning communication, and intelligible verbalization). For DOC patients, the differential diagnosis of consciousness state is of great importance, especially for decisions on treatment, care, and end-of-life actions [2, 6]
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