Abstract
Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association’s Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings from the systematic review on the effectiveness of mobility interventions to improve arousal and awareness in people with disorders of consciousness following a traumatic brain injury.
Full Systematic Review Question
This systematic review addressed the question “What is the evidence for the effectiveness of interventions to improve arousal and awareness for people in a disordered state of consciousness post TBI?”
Current Theme Reported
The main theme of the studies included in this systematic review brief is mobility interventions.
Clinical Scenario
More patients are surviving a traumatic brain injury (TBI) because of improvements in early resuscitation, interventions, and rehabilitation (Claassen et al., 2021). Increased survival is evident for patients with disorders of consciousness (DoC) following a severe TBI. DoC diagnoses include comatose, vegetative state/unresponsive wakefulness syndrome, and minimally conscious state (MCS). Neurobehavioral function outcome measures may include items that capture whether a patient has emerged from MCS. Recent practice guidelines recommend practitioners use standardized neurobehavioral assessment measures to improve diagnostic accuracy for disordered states of consciousness, identify trends in the patient’s recovery trajectory, and have effective rehabilitation care (Giacino et al., 2018). Evidence demonstrates that patients can experience meaningful functional recovery 5- and 10-yr postinjury (Hammond et al., 2019; Whyte et al., 2013). We provide the current evidence about interventions that can be provided by occupational therapy practitioners as part of treatment plans for adults with DoC. This systematic review brief includes mobility interventions.
Summary of Key Findings
Four studies that used a mobility intervention met the criteria for inclusion in this systematic review (Table 1). The four mobility intervention studies were delineated into two subthemes, passive mobilization (two studies) and tilt table with robotic stepping (two studies). Passive mobilization included passive range of motion, sitting upright at the edge of the bed (i.e., position changes), and use of a tilt table to vary the patient’s degree of being upright. Tilt table with robotic stepping meant that patients were stepping between 0 and 80 steps per minute using a device in addition to the tilt table. Low strength of evidence supports these interventions because of a limited number of studies. The levels of evidence used in this review are from Oxford Centre for Evidence-Based Medicine (2009). Study participants made statistically significant improvements across all four studies.
Evidence Table for Mobility Interventions To Improve Arousal and Awareness for People in a Disordered State of Consciousness Post TBI
Note. CRS-R = Coma Recovery Scale–Revised; DoC = disorders of consciousness; ICU = intensive care unit; RCT = randomized, controlled trial; TBI = traumatic brain injury; FIM = functional independence measure; GOS = Glasgow Outcome Scale.
Bottom Line for Occupational Therapy Practice
Overall, occupational therapy practitioners can use passive mobilization and tilt table with robotic stepping as interventions to facilitate arousal and awareness.
Passive Mobilization
Although both studies showed statistically significant improvements compared with baseline, the study using a tilt table indicated that patients were not able to tolerate 20 min of mobilization (Riberholt et al., 2013). However, the patients using the tilt table, including those who used it <20 min, demonstrated more time with their eyes open when compared with the control period. The second study found that early mobilization of participants led to statistically significant improvements. Therefore, occupational therapy practitioners should consider advocating to medical providers for an order to evaluate and treat early in the care process.
Tilt Table With Robotic Stepping
Of the two studies that evaluated the combination of a tilt table with a robotic stepping device, one reported a significantly better outcome when stepping was included in the intervention and the other study reported a significantly better outcome using a tilt table only with no stepping. For both studies, the intervention group and control groups demonstrated significant improvements. Although more evidence is required to establish efficacy, occupational therapy practitioners may consider using tilt tables (with or without passive mobilization and/or stepping) to facilitate recovery of consciousness.
Frazzitta et al. (2016) showed significant improvements on all outcome measures, but the experimental group had significantly better improvements on the Coma Recovery Scale–Revised (CRS-R) throughout the study period compared with the control group receiving conventional physiotherapy. Krewer et al. (2015) showed significant improvements on the CRS-R in both groups, but the control group receiving tilt table only was significantly better than the intervention group (tilt table and robotic stepping). There are key differences between these two studies which include the following: the participants’ time since injury, type of control group, duration and frequency of the intervention, stepping frequency, and location of intervention delivery. Frazzitta et al. (2016) included participants within their first month of injury and the control group received standard physiotherapy for 60 min. The intervention group received 15 30-min sessions of tilt table and robotic stepping at 20 steps/min in the intensive care unit. Krewer et al. (2015) included participants 4- to 14-wk postinjury and the control group received tilt table only. The intervention group received ten 60-min sessions of tilt table and robotic stepping (frequency of stepping not reported) in inpatient rehabilitation; all participants were receiving therapy and nursing services. Additional research is needed to understand the optimal time since injury for using a tilt table with robotic stepping, whether the addition of robotic stepping to verticalization facilitates arousal and/or awareness and if so the recommended frequency of stepping.
We did not find research that examined using a tilt table for verticalization with preferred stimuli to address other senses (e.g., auditory, visual, olfactory, gustatory). It is possible that when using a tilt table, occupational therapy practitioners may be cotreating and could incorporate the patient’s preferred stimuli as part of an occupation-centered treatment plan for adults with disorders of consciousness following TBI.
Footnotes
*
Indicates articles included in the brief systematic review.