Coma and Disorders of Consciousness by Caroline Schnakers & Steven Laureys

Author:Caroline Schnakers & Steven Laureys
Language: eng
Format: epub
Publisher: Springer International Publishing, Cham

Clinical Recommendations

Since the process of muscle contracture initiating muscular atrophy is acute (occurring within the first 6 h of immobilization) [42, 93], early mobilization (passive ROM) is crucial in order to avoid premature complications. Although the main objective in the intensive care unit is to keep a sufficient lung function, the motor issue should not be put aside. Actually, any type of treatment, pharmacological or non-pharmacological, should be started early, as soon as muscle overactivity is distributed diffusely and causes clinical disability, in order to prevent permanent articular deformities or muscle contractures. Afterward, even if it is often unknown in the acute setting if the patients will or not fully recover, an early post-acute care should be provided in a specialized rehabilitation center where patients can be properly assessed, and a suitable care program can be established. Further, at the chronic stage, using soft and comfortable splints to decrease spasticity should be recommended [87], in addition to the existent treatments, since patients with DOC are not able to communicate their pain feelings.

Physiotherapists will have a key role to play although little is known about the effect of intensity of physiotherapy on motor outcomes [15]. They are strongly involved in the patient’s care and rehabilitation by seeing them nearly every day for respiratory physiotherapy, stretching, positioning, multisensory stimulation programs, and much more, in order to enhance the comfort and stimulate patients’ arousal. Regarding spasticity in particular, physiotherapists have to position and stretch them right for several hours a day in order to manage the muscular tone, to avoid any contracture and to maintain the skin integrity [94–96]. In order to effectively improve the function and comfort of patients with DOC, the physiotherapist’s interventions have to be frequent and of prolonged duration. However, the cost for the social security is high. Future studies have to clarify the minimal but sufficient amount of physiotherapy in acute and chronic situations and establish evidence-based guidelines for the spasticity management.

Naturally, a multidisciplinary approach combining physical, pharmacological, and surgical treatment interventions is needed to manage this spasticity properly [82]. Not only the therapists but the families have a significant role to play [97], and they should be encouraged to take part in the care by gently stretching, massaging, and stimulating their relatives every day, beside physical therapy or oral therapy sessions. At a prolonged chronic stage, the emphasis is more on maintaining quality of life than preserving function toward the expectation of future recovery since the chances of recovery are less likely to occur [94].

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