ABSTRACT
Objectives:
In Japan, few patients with prolonged disorders of consciousness (pDoC) receive appropriate evaluation of consciousness, and their physical status is unclear. We investigated state of consciousness and the incidence of spasticity and contracture in patients with pDoC.
Methods:
We assessed state of consciousness by using the Coma Recovery Scale-Revised (CRS-R). We evaluated physical status using the Modified Ashworth Scale (MAS) and range of motion (ROM). At Hospital A, patients did not receive rehabilitation, whereas patients at Hospital B received continuous rehabilitation.
Results:
Nine (33.3%) patients out of 27 were assessed as emergence from minimally conscious state (EMCS) at Hospital A, compared with 10 (27.8%) patients out of 36 at Hospital B. The mean ankle joint MAS score was higher in patients at Hospital A than at Hospital B. The mean ROM for ankle dorsiflexion was lower in patients at Hospital A than those at Hospital B. The mean elbow joint MAS score was lower in the EMCS group relative to the minimally conscious state (MCS) group. The mean ankle joint MAS score was lower in the EMCS group relative to the unresponsive wakefulness syndrome (UWS) group. Multiple regression analyses showed that admitted facility (Hospital A or Hospital B) was associated with ankle joint MAS scores and ankle dorsiflexion ROM, but was independent of age, classification of DOC, and time from onset to evaluation.
Conclusions:
Some patients with pDOC may show improvement in status of consciousness. This study suggests that rehabilitation can reduce ankle spasticity and contracture in patients with pDOC.
Keywords: contracture, disorders of consciousness, equinus, range of motion, spasticity
INTRODUCTION
As advances continue to be made in emergency and critical care medicine, the number of patients who survive severe brain injuries is increasing. Consequently, the number of patients who experience prolonged disorders of consciousness (pDoC) following severe brain injury is also increasing.1) Disorders of consciousness are categorized into coma, the most severe form of this disorder in which the patient cannot be aroused, the unresponsive wakefulness syndrome (UWS),2) in which the patient is awake but unable to distinguish and recognize self and surroundings, and the minimally conscious state (MCS),3) in which the patient shows minimal recognition of self and surroundings.
In 2018, the American Congress of Rehabilitation Medicine (ACRM) and the National Institute on Disability, Independent Living, and Rehabilitation Research published guidelines on the management of patients with disorders of consciousness.4) These guidelines recommend that a patient’s level of consciousness be assessed serially over time using standardized assessment scales. Some patients with disorders of consciousness may regain consciousness after several months or years.5) Serially assessing the level of consciousness over time using standardized assessment scales enables capturing improvements of disturbed consciousness. Patients with disorders of consciousness may develop various complications.6) The Minimum Competency Recommendations for rehabilitation services published in 2020 recommend that patients with disorders of consciousness should be managed in a way that prevents the development of nutritional deficiency, aspiration pneumonia, pressure ulcers, deep vein thrombosis, muscle tone abnormality, and contractures.7) Among these complications, spasticity and contractures interfere with physical function and inhibit improvements in patients’ activities of daily living.
Although the importance of adequately managing patients with disorders of consciousness has been advocated, it was reported that patients with severe disorders of consciousness in an acute care hospital were often judged to have no chance of improvement in the future and had fewer opportunities to receive continuous rehabilitation.8) It was also found that pDoC resulted in increased instances of withdrawal or withholding care.9) A study based on a survey of medical professionals in Japan reported that discharge coordination in acute care hospitals for patients with disorders of consciousness was difficult in many cases because of the “lack of facilities that can accept patients who require a large number of medical procedures.”10) Therefore, concerningly, many patients with consciousness disorders may not be receiving appropriate rehabilitation. However, to our knowledge, no reports of patients with pDoC in Japan have been published, nor has there been sufficient discussion about such patients.
The purpose of the current study was to investigate the level of consciousness and the incidence of spasticity and contracture in patients with pDoC in two hospitals in Japan. We hypothesized that patients in rehabilitation settings would show better physical function and similar or improved levels of consciousness compared with those in non-rehabilitation settings.
MATERIALS AND METHODS
Patients
The study included patients who were hospitalized at Sekino Hospital or Ryokuseikai Hospital between December 2022 and December 2024. Patients were included in the study based on the following criteria: (1) aged 18 years or older; (2) with new brain damage, such as cerebrovascular disease, traumatic brain injury, or hypoxic encephalopathy and without previous neurological diseases; (3) Glasgow coma scale below 8 at the time of hospital admission11); (4) their general condition stabilized after 4 weeks following disease onset; (5) at least 24 h passed since the end of the sedation if sedation was used; and (6) they had not been given an antispastic drug. Patients were excluded from the study according to the following criteria: (1) consent was withdrawn by the patient (or their surrogate); (2) unknown cause of consciousness disorder; or (3) consciousness or physical function could not be assessed.
The current study adhered to the Declaration of Helsinki and was approved by the ethics committees of Sekino Hospital (approval number N2022001) and Ryokuseikai Hospital (approval number 0401). The purpose and methods of the study were explained to family members, close relatives, or proxies, and written consent was obtained.
Assessment
We used the Coma Recovery Scale-Revised (CRS-R) to assess the level of consciousness.12) The CRS-R consists of six subscales assessing auditory function, visual function, motor function, speech and oral function, communication, and arousal. The highest score for each scale reflects behaviors related to consciousness, and the lowest score reflects reflexive activity. Assessment by the CRS-R enables the classification of disorders of consciousness, such as UWS and MCS (or emergence from MCS; EMCS). The CRS-R assessment in the current study was conducted by a physician, occupational therapist, or physical therapist.
The Modified Ashworth Scale (MAS) was used to assess spasticity in both elbow and ankle joints by an occupational therapist or physical therapist who was blind to the results of the CRS-R assessment.13,14) The MAS assesses muscle tone during passive joint movement of the target joint on a six-point scale (0, 1, 1+, 2, 3, and 4). Higher scores indicate stronger spasticity, and 0 indicates no spasticity. In the assessment of spasticity in the elbow joint, the patient’s elbow joint was maximally flexed while the patient was in the supine position, with the forearm in the neutral position, and the elbow was extended to maximum extension over about 1 s. To assess spasticity in the ankle joint, the patient’s ankle joint was plantar flexed with the hip joint in a neutral rotation and the knee joint in a flexion position. Then, the ankle joint was extended from the maximum possible plantar flexion to the maximum possible dorsal flexion for approximately 1 s.
The range of motion (ROM) for the extension of both elbow joints and the dorsiflexion of both ankle joints was measured by an occupational therapist or a physical therapist who was blind to the results of the CRS-R assessment. When measuring the ROM of elbow joint extension, the patient was placed in the supine position, with the shoulder joint in the neutral position and the forearm in the supinated position as much as possible. Then, the elbow joint was extended as slowly as possible. The elbow joint was fixed at the end of the range of motion for elbow extension, and the angle from the baseline to the end of the range of motion was measured using a goniometer. In the ROM measurement of ankle dorsiflexion, the patient was placed in the supine position, with the hip joint in the neutral rotation and the knee in the flexed position. The ankle joint was then dorsally flexed as slowly as possible. The ankle joint was fixed at the end of the range of motion of dorsiflexion, and the angle from the baseline to the final range of motion was measured using a goniometer. The ROM measurement was performed after the MAS assessment.
Rehabilitation
At Hospital A, rehabilitation was not provided to any of the patients. At Hospital B, as well as auditory and visual stimulation, the patients who participated in the study underwent training that covered the range of motion of the joints of the limbs, stretching, and mobility training. Mobility training included sitting up, turning over, standing up, transferring, and getting out of a wheelchair (evaluating factors such as blood pressure fluctuations and increasing the duration of continuous time away from the wheelchair).
Statistical Analysis
For parametric variables, independent t-tests were performed for comparisons between two groups that are independent. Kruskal-Wallis tests were performed for comparison among three independent groups. For nominal variables, the Fisher’s Exact Test was performed. Multiple comparisons were carried out using the Bonferroni method for a comparison involving three or more groups. The mean values of ROM and MAS were calculated, and multiple regression analyses were performed using these as dependent variables. Statistically significant difference was recognized for P <0.05. All statistical analyses were conducted with SPSS version 30.0 (IBM, Armonk, NY, USA).
RESULTS
The characteristics of the patients are shown in Table 1. Patients at Hospital A were significantly younger than those at Hospital B. No other patient characteristics showed significant difference between the two hospitals. Table 2 shows the results of the assessment of the consciousness and physical function of the patients. The mean MAS score of the ankle joint was significantly higher in patients at Hospital A than in Hospital B. The number of patients with a MAS score greater than or equal to 1 did not differ significantly between the two hospitals, but the number of patients with high spasticity with a MAS score greater than or equal to 3 was significantly higher in Hospital A. The mean ROM for ankle dorsiflexion was significantly lower in patients at Hospital A than in those at Hospital B. In addition, the number of patients with a dorsiflexion limit below 0° was significantly higher in Hospital A. Classification of disorders of consciousness by the CRS-R revealed that Hospital B had a higher proportion of MCS relative to UWS, but the proportion of EMCS was not different between the two groups.
Table 1. Patient characteristics.
| Characteristic | Hospital A (n = 27) | Hospital B (n = 36) | P value |
| Sex | 0.094 | ||
| Male | 17 (63.0) | 15 (41.7) | |
| Female | 10 (37.0) | 21 (58.3) | |
| Age, years | 63.6 | 78.6 | <0.001 |
| Time from onset to evaluation, days | 238.9 | 183.7 | 0.163 |
| Underlying illness | 0.076 | ||
| Traumatic brain injury | 5 (18.5) | 1 (2.8) | |
| Non-traumatic brain injury | 22 (81.5) | 35 (97.2) |
Data presented as number (percentage) or as mean.
Table 2. Evaluation of consciousness and physical function.
| Evaluation | Hospital A (n = 27) | Hospital B (n = 36) | P value |
| MAS score | |||
| Elbow | 1.0 ± 1.0 | 1.2 ± 0.7 | 0.15 |
| Ankle | 2.0 ± 1.4 | 1.1 ± 0.8 | 0.002 |
| MAS ≥1 | 24 (88.9) | 31 (86.1) | 0.743 |
| MAS ≥3 | 14 (51.9) | 6 (16.7) | 0.003 |
| ROM, degrees | |||
| Elbow extension | −34.1 ± 35.9 | −29.6 ± 24.2 | 0.29 |
| Ankle dorsiflexion | −15.1 ± 12.1 | −9.1 ± 11.8 | 0.03 |
| Severe elbow flexural contracture a | 7 (25.9) | 5 (13.9) | 0.229 |
| Severe ankle plantarflexion contracture b | 24 (88.9) | 24 (66.7) | 0.04 |
| DOC classification by CRS-R | |||
| UWS | 9 (33.3) | 3 (8.3) | |
| MCS | 9 (33.3) | 23 (63.9) * | |
| EMCS | 9 (33.3) | 10 (27.8) | |
| CRS-R total score c | 12.6 ± 6.7 | 12.8 ± 5.6 | 0.46 |
Data presented as mean ± standard deviation or number (percentage).
a Extension limit > −90 degrees; b Ankle dorsiflexion <0°; c Mean CRS-R total score.
* P = 0.021 for comparison of MCS with UWS for Hospital B.
Figure 1 shows the average MAS and ROM values for each category of disorders of consciousness. The mean MAS score of the elbow joint was significantly lower in the EMCS group than in the MCS group. The mean MAS score of the ankle joint was significantly lower in the EMCS group than in the UWS group. In the UWS group, the median duration from onset to evaluation was 105 days [interquartile range (IQR), 75.25–165.25]. In the MCS group, the median duration from onset to evaluation was 133 days (IQR, 86–287.75). In the EMCS group, the median duration from onset to evaluation was 230 days (IQR, 73–327).
Fig. 1.
Average MAS and ROM values (elbow and ankle) for each category of DoC. (A) Average MAS score of the elbow: mean elbow joint MAS score was significantly lower in the EMCS group than in the MCS group (P = 0.004). (B) Average MAS score of the ankle: mean ankle joint MAS score was significantly lower in the EMCS group than in the UWS group (P = 0.024). (C) Average ROM of the elbow: there was no significant difference among the three DoC groups (P = 0.47). (D) Average ROM of the ankle: there was no significant difference among the three DoC groups (P = 0.59).
Multiple regression analyses conducted using age, admitted facility (Hospital A or Hospital B), classification of disorders of consciousness (UWS, MCS, or EMCS), and the time from onset to evaluation as explanatory variables revealed that the classification of disorders of consciousness, admitted facility, and the time from onset to evaluation were related to ankle joint MAS scores (Table 3). The admitted facility was associated with ankle dorsiflexion ROM, as shown in Table 4. Tables 5 and 6 show that these variables were not related to MAS scores and ROM in the elbow joint.
Table 3. Multiple regression analysis for ankle dorsiflexion MAS score.
| Explanatory variable | B | β | 95% Confidence interval | P value |
| Age | −0.004 | −0.057 | −0.024 to 0.015 | 0.664 |
| Facility | 0.671 | 0.288 | 0.057 to 1.284 | 0.033 |
| Time from onset to evaluation | 0.002 | 0.306 | 0.000 to 0.003 | 0.009 |
| Classification of DoC | −0.437 | −0.263 | −0.824 to −0.050 | 0.027 |
B, Unstandardized coefficient; β, standardized coefficient.
Table 4. Multiple regression analysis for ankle dorsiflexion ROM.
| Explanatory variable | B | β | 95% Confidence interval | P value |
| Age | −0.101 | −0.127 | −0.335 to 0.133 | 0.390 |
| Facility | −0.498 | −0.288 | −1.018 to 0.022 | 0.049 |
| Time from onset to evaluation | −0.007 | 0.111 | −0.022 to 0.009 | 0.394 |
| Classification of DoC | −0.287 | −0.232 | −0.635 to 0.061 | 0.104 |
B, Unstandardized coefficient; β, standardized coefficient.
Table 5. Multiple regression analysis for elbow extension MAS score.
| Explanatory variable | B | β | 95% Confidence interval | P value |
| Age | −0.011 | −0.203 | −0.028 to 0.005 | 0.170 |
| Facility | −0.489 | −0.283 | −1.004 to 0.025 | 0.062 |
| Time from onset to evaluation | 0.001 | 0.148 | 0.000 to 0.002 | 0.252 |
| Classification of DoC | −0.264 | −0.213 | −0.588 to 0.060 | 0.109 |
B, Unstandardized coefficient; β, standardized coefficient.
Table 6. Multiple regression analysis for elbow extension ROM.
| Explanatory variable | B | β | 95% Confidence interval | P value |
| Age | 0.246 | 0.128 | −0.34 to 0.83 | 0.40 |
| Facility | 1.226 | 0.021 | −17.15 to 19.60 | 0.89 |
| Time from onset to evaluation | −0.019 | −0.133 | −0.06 to 0.020 | 0.32 |
| Classification of DoC | 4.838 | 0.114 | −7.46 to 17.13 | 0.43 |
B, Unstandardized coefficient; β, standardized coefficient.
DISCUSSION
The results of this study showed that approximately 30% of patients with pDoC were in the EMCS state 4 weeks or more after the onset of their condition. This suggests that some patients who have pDoC showed improvement in their level of consciousness. In patients with EMCS, elbow and ankle spasticity was mild. In addition, we found that patients with pDoC in Hospital A (no rehabilitation) had worse ankle spasticity and contracture than those in Hospital B.
There was no difference in the proportion of patients with EMCS between the two facilities. Therefore, it is possible that rehabilitation, such as that provided in Hospital B, would not contribute to improved level of consciousness. However, it has been reported that sitting position training and standing position training, as well as standing training with a tilt table, improved the level of consciousness.15,16,17) A randomized controlled trial is needed to examine the effect of rehabilitation on the level of consciousness.
Patient spasticity was worse in the facility that did not provide rehabilitation when compared with the facility that provided rehabilitation. Stretching as a rehabilitation technique is reportedly effective for spasticity in patients with disorders of consciousness.18) In the current study, we saw spasticity above a MAS score of 1 in 87% of the patients. This is consistent with 88%, which was reported in a previous study that examined the prevalence of spasticity in patients with disorders of consciousness.19) However, in the current study, the percentage of patients with severe spasticity (MAS score ≥3) was 16.7% in the facility that provided rehabilitation, compared to 51.9% in the facility that did not provide rehabilitation. One study reported that severe spasticity (MAS score ≥3) was observed in approximately 60% of patients with disorders of consciousness,19) and the results of the current study suggest that rehabilitation may suppress the exacerbation of spasticity.
Spasticity is a major cause of contracture.20) Moreover, patients with impaired consciousness are reportedly prone to contractures.21) In the current study, there was no significant difference in elbow joint extension restriction when compared between the hospital that provided rehabilitation and the hospital that did not provide rehabilitation. However, in the hospital that provided rehabilitation, the ankle dorsiflexion restriction was greater than in the hospital that did not provide rehabilitation. Foot deformities with restricted dorsiflexion are called equinus, although a clear definition of equinus has not been established.22) A dorsiflexion ROM of less than 10 degrees may be regarded as equinus,22) but some propose that a dorsiflexion ROM of less than 0 degrees should be called equinus.23) The more severe restriction of dorsiflexion of the ankle joint would result in increased forefoot pressure during the flat foot stage of gait, negatively affecting walking.24) ROM restrictions and spasticity of the foot can also cause significant problems with wearing shoes, standing, and transfers.25) Upper-limb spasticity and contracture have been reported to be associated with increased caregiver burden because of hygiene considerations and dressing difficulty.18,26)
Stretching is reportedly effective for spasticity in patients with disorders of consciousness.18) In the current study, stretching may have suppressed the progression of contracture in the hospital that provided rehabilitation.
This study was a cross-sectional, small-scale observational study, and interpretation of the results requires caution. To examine whether there are any effects of rehabilitation on reducing spasticity and contracture and improving consciousness disturbance, it will be necessary to conduct large-scale randomized controlled trials. In the current study, only the elbow and ankle joints were evaluated as measures of physical function. This decision was based on previous reports that spasticity often occurs in the elbow and ankle joints after brain injury.27,28) In addition, patients with disorders of consciousness are reportedly prone to contractures in the ankle joint.29) To fully understand the physical function of patients with pDoC, it is necessary to evaluate the spasticity and ROM of joints, including the shoulders, elbows, wrists, fingers, hips, knees, and ankles.
In summary, this study showed that about 30% of patients with disorders of consciousness were in the EMCS status in the chronic phase. Lack of rehabilitation may exacerbate spasticity and contracture in patients with pDoC.
ACKNOWLEDGMENTS
This work was supported by the Japan Society for the Promotion of Science through a Grant-in-Aid for Scientific Research (Grant Number 24K20542).
Footnotes
CONFLICTS OF INTEREST: The authors declare no conflict of interest.
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