Physiotherapeutic Management of a Sitting Program for Subjects with Altered Consciousness: A Case Series

doi:10.21203/rs.3.rs-3717968/v1

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Physiotherapeutic Management of a Sitting Program for Subjects with Altered Consciousness: A Case Series

https://doi.org/10.21203/rs.3.rs-3717968/v1

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Background/Objective:

The verticalization of subjects with altered consciousness through a standing table or sitting generates improvements in their behavior, wakefulness, and level of consciousness. The objective of this study was to describe the physiotherapeutic management of a verticalization program for subjects with altered consciousness in acute and subacute stages.

Methods

Subjects with a diagnosis of altered consciousness and fluent in Spanish were included, while those with missing 20% of data were excluded. A sitting program was conducted for 30 minutes a day for 10 days, measuring the change in the level of consciousness using the Revised Coma Scale and monitoring adverse effects.

Results

Out of the eight subjects included in the study, seven exhibited improvements in their level of consciousness, with only one subject experiencing adverse effects during the sitting program. One subject was eliminated from the study due to incomplete data.

Conclusions

This study provides a comprehensive description of the physiotherapeutic management of a verticalization program for subjects with altered consciousness during the acute and subacute stages. The majority of included subjects demonstrated an improvement in their level of consciousness.

Neurorehabilitation

Rehabilitation

Altered consciousness

Case series

Sitting position

Coma Recovery Scale-Revised

Altered consciousness is an organic mental disorder characterized by a diminished capacity to maintain self-awareness and awareness of the environment and respond to environmental stimuli ⁽¹⁾. The minimum prevalence of prolonged consciousness disorders is estimated to be 5/100,000 people, with an annual incidence of 5/100,000 people for all causes ⁽²⁾. While many individuals recover consciousness quickly, some remain with altered consciousness for extended or permanent periods ⁽³⁾.

Rehabilitation in these subjects has been shown to reduce mortality, accelerate rehabilitation processes, decrease disability, and reduce the level of care required by family members ⁽³⁾. Intense stimulation can help patients wake up, and repetitive stimulation can promote the training of previously unused parts of the brain ⁽⁴⁾.

Dysfunction of the cerebral hemispheres or the reticular formation of the brainstem can result in this condition ⁽¹⁾. Alterations in the reticular activating system (RAS) can lead to sleep disturbances, attention deficits, learning difficulties, and memory impairments ⁽⁵⁾. Furthermore, the RAS is involved in preconscious awareness of sensory perception and the intention of voluntary movement, both of which are essential for the formation of our sensations and movements ⁽⁵⁾.

Previous studies have demonstrated that verticalization of these subjects using a standing table results in improvements in behavior ⁽⁶⁾, wakefulness ⁽⁷⁾, and level of consciousness ^(8,9).

In Australia, during the acute hospitalization period, less than 70% of physiotherapists use standing tables as a therapeutic strategy, with lack of time cited as one of the reasons in nearly 18% of cases ⁽¹⁰⁾. However, such devices are not widely available in most acute care centers in middle- and low-income countries.

Verticalization can also be achieved through sitting. Previous studies have shown its effectiveness in improving the level of consciousness in subjects with altered consciousness ^(11,12).

However, the majority of studies demonstrating benefits with verticalization as a therapeutic strategy have not used the Revised Coma Recovery Scale (CRS-R), which is the tool that generates the least uncertainty according to the American Congress of Rehabilitation ⁽¹³⁾.

To our knowledge, there are no studies that have evaluated the effectiveness of sitting in subjects with altered consciousness using the CRS-R and assessed the safety of this therapeutic strategy.

Objective

To describe the physiotherapeutic management of a verticalization program for subjects with altered consciousness in acute and subacute stages.

Location and Participants

The study was conducted by collecting data from patients with altered consciousness in the inpatient ward of La Sagrada Familia Clinic. The review period was from February 1, 2022, to June 2023.

The included subjects were: those diagnosed with altered consciousness, either presenting a minimally conscious state or an unresponsive wakefulness syndrome/vegetative state. The diagnosis was established using the Revised Coma Recovery Scale (14).Fluent in Spanish. Subjects with 20% or more missing data were excluded.

Intervention

The included subjects were exposed to a verticalization program through a ten-day sitting intervention, 30 minutes per day on weekdays. Two physiotherapists were responsible for the intervention. For those who lacked head control, one of them controlled the orientation of the head and neck relative to the vertical position. Throughout the intervention, subjects had various posterior and lateral supports to improve positioning (without pelvic rotation, hips, knees, elbows, and ankles at 90°). The collected variables are detailed in Supplemental Material 1.

The following criteria were used to initiate the intervention each day:

Systolic blood pressure between 100 and 220 mmHg ^(15,16).
SpO2 > 90% or oxygen therapy was administered to achieve SpO2 levels of 94–98% for patients at risk of hypercapnia, and SpO2 levels of 88–92% for patients with risk factors ⁽¹⁷⁾.
Heart rate greater than 40 and less than 100 beats per minute ⁽¹⁸⁾.
Temperature lower than 38.5°C or higher than 35°C ⁽¹⁹⁾.

The following criteria were used to halt sitting:

Presence of orthostatic hypotension: Defined as a drop of 20 mmHg in systolic blood pressure or 10 mmHg in diastolic blood pressure after 3 minutes of sitting, compared to the supine position ⁽¹⁹⁾.
Increase of 30 beats per minute in baseline heart rate ⁽²⁰⁾, or a heart rate equal to or less than 40 beats per minute.
Presence of tachypnea: Noted when the respiratory rate exceeds 35 breaths per minute ⁽²¹⁾.
If there was no blood pressure monitoring available, the last two criteria were taken into account to consider discontinuing the intervention for that day and were recorded as an adverse event for that subject.

Data Collection

The primary outcome of this case series was the Revised Coma Recovery Scale, Argentine version ⁽²²⁾. Subjects were identified through electronic medical record searches during the pre-specified time period. The data were uploaded to a database by one author (G.C) and validated by two authors (D.L and C.T). The data will be presented individually as the purpose of this study design is not to evaluate the effectiveness of a treatment ⁽²³⁾. The procedure manual is available in Supplemental Material 2.

Ethical Aspects

The protocol of this study was carried out following the approval of the IRB of Universidad Abierta Interamericana.

Due to the retrospective nature of the protocol, obtaining informed consent was not utilized as only non-identifiable data were used ⁽²³⁾. The confidentiality of the data was safeguarded in accordance with the provisions of Law 25326 ⁽²⁴⁾.

Conceptual and Operational Definition of Variables

The following variables were collected:

Age: Defined as the years elapsed since the date of birth ⁽²⁵⁾. Recorded as a continuous quantitative variable (Years).
Sex: Defined as the totality of reproductive structure, functions, phenotype, and genotype characteristics that differentiate male from female organisms ⁽²⁶⁾. Classified as a dichotomous qualitative variable (Female/Male).
Time of evolution: Calculated as the difference between the admission date and the date of the first evaluation. Recorded as a continuous quantitative variable (days).
Etiology: Used with diseases to refer to causative agents, including microorganisms, environmental and social factors, and personal habits as contributing factors ⁽²⁷⁾. Categorized as a polytomous qualitative variable (Vascular/Traumatic/Anoxic/Other).
Tracheostomy: Defined as the surgical formation of an opening in the trachea through the neck ⁽²⁸⁾. Classified as a dichotomous qualitative variable (Yes/No).
Feeding: Categorized as a polytomous qualitative variable (Nasogastric tube/Gastric button/Other).
Site of Lesion: Categorized as a polytomous qualitative variable (Supratentorial/Infratentorial/Both).
Craniotomy: Excision of part of the skull ⁽²⁹⁾. Classified as a dichotomous qualitative variable (Yes/No).
Medication: Categorized as a polytomous qualitative variable (Amantadine/Levodopa/Bromocriptine/Apomorphine/Methylphenidate/Zolpidem/Baclofen/Lamotrigine/Lorazepam/Anticonvulsants/Other).
Quantity of Anticonvulsants: Recorded as a discrete quantitative variable.
Level of Consciousness: Categorized as a polytomous qualitative variable (Minimally Conscious State/Unresponsive wakefulness syndrome/Emerging from Minimally Conscious State).
Revised Coma Recovery Scale: Recorded as a continuous quantitative variable (Points).
Auditory Subscore: Recorded as a continuous quantitative variable (Points).
Visual Subscore: Recorded as a continuous quantitative variable (Points).
Motor Subscore: Recorded as a continuous quantitative variable (Points).
Oromotor Subscore: Recorded as a continuous quantitative variable (Points).
Communication Subscore: Recorded as a continuous quantitative variable (Points).
Wakefulness Subscore: Recorded as a continuous quantitative variable (Points).
Sessions: Recorded as a discrete quantitative variable.
Completion: Classified as a dichotomous qualitative variable (Yes/No).
Reason: Classified as a polytomous qualitative variable (Referral/Death/Other).
Orthostatic Hypotension: Defined as a significant drop in blood pressure after assuming a standing position. Orthostatic hypotension is defined as a decrease of 20 mm Hg in systolic blood pressure or a decrease of 10 mm Hg in diastolic blood pressure 3 minutes after a person has risen from a supine position to an upright position ⁽³²⁾. Classified as a dichotomous qualitative variable (Yes/No).
Frequency of Orthostatic Hypotension: Recorded as a continuous quantitative variable.
Tachycardia: Defined as an abnormally rapid heart rate, typically with a heart rate exceeding 100 beats per minute in adults ^(32,33). Classified as a dichotomous qualitative variable (Yes/No).
Frequency of Tachycardia: Recorded as a continuous quantitative variable.
Bradycardia: Defined as an excessively slow heart rate, typically below 50 beats per minute in adult humans. Classified as a dichotomous qualitative variable (Yes/No).
Frequency of Bradycardia: Recorded as a continuous quantitative variable.
Tachypnea: Defined as an increased respiratory rate, reaching more than 35 breaths per minute ^(34,35). Classified as a dichotomous qualitative variable (Yes/No).
Frequency of Tachypnea: Recorded as a continuous quantitative variable.

Funding

This research did not receive specific assistance from public sector agencies, commercial sector, or non-profit organizations.

The sample consisted of eight subjects, four males, aged between 63 and 83 years, with pathology of vascular etiology, except for one subject that presented an occupying space lesion, and a duration of illness ranging from 16 to 73 days. Three of the subjects underwent decompressive craniectomy, and only one did not require anticonvulsants. Prior to the start of the study, 12.5% experienced vasospasm, 25% had rebleeding, and 37.5% had a seizure status. Clinical and demographic characteristics are shown in Table 1.

Seven subjects completed the intervention in its entirety; subject seven did not finish it due to referral to another institution. On the other hand, subject five experienced orthostatic hypotension on two occasions when sitting up.

Regarding the post-intervention course, six subjects showed an increase in the total CRS-R score. Subject four underwent a change in consciousness state from unresponsive wakefulness syndrome to minimal consciousness state. Subject five showed modifications in scale subscores without variations in the total score. The results of the evaluations at the beginning and end of the interventions for each subject are presented in Table 2.

In the present study, the management and implementation of a physiotherapeutic verticalization program in subjects with altered consciousness were described. The results showed a change in the consciousness state of one subject and an improvement in the total CRS-R score in six out of eight subjects. It is worth mentioning that all subjects exhibited modifications in the sub-scores of the CRS-R scale. Additionally, Subject 3 showed improvements in the total CRS-R score despite having the longest evolution time, suggesting that changes in consciousness may occur regardless of the duration of evolution.

Moriki et al. assessed changes in the level of consciousness after sitting in individuals with brain conditions (stroke, brain injury, tumor, or hypoxia) using the Glasgow Coma Scale, reporting a significant improvement in the sitting position compared to the supine position ⁽¹¹⁾. Toccolini et al. reported improvements in the Glasgow Coma Scale score and alertness status (using the Richmond Agitation-Sedation Scale) with visual contact during a passive standing intervention on a tilting table ⁽⁸⁾. Our results align with these studies; however, consciousness state was not evaluated with the CRS-R, emphasizing the importance of objective assessment using this scale ⁽⁸⁾.

In the literature, various scales such as GCS and CRS-R are implemented to assess subjects' alertness levels. However, the latest guidelines from the European Academy of Neurology recommend using CRS-R to diagnose the level of consciousness in individuals with consciousness disorders, as done in our study. Nevertheless, this scale does not encompass the assessment of cognitive motor dissociation, which may occur in a minority of our study population, as reported by Fins et al. (present in 4 or 5 out of 50 subjects) ^(36–38). Additionally, Krewer et al. evaluated the influence of early mobilization using a tilting table and a stepped verticalization device in subjects with traumatic and non-traumatic brain injury and altered consciousness. Both groups significantly improved consciousness during the three-week intervention period through CRS-R, suggesting that verticalization seems beneficial and should be administered to subjects with altered consciousness ⁽³⁹⁾. Conducting a randomized controlled study on early sensory stimulation with verticalization, as performed in our study, would be relevant to ascertain reported consciousness benefits with greater therapeutic strategy accessibility.

Wilson et al. evaluated the effect of sitting compared to supine and standing positions in subjects, half of whom were in an unresponsive wakefulness syndrome, and the other half in a minimally conscious state; the Wessex Head Injury Matrix was used for evaluation. They reported a 63% improvement compared to the supine position, and 69% responded better to the vertical position compared to sitting. In our study, treatment initiation times were much shorter ⁽⁴⁰⁾.

During our study, only one subject experienced orthostatic hypotension on two occasions, which was promptly detected by the staff, leading to immediate appropriate intervention and complete recovery to baseline. Riberholt et al. reported that subjects with severe subacute acquired brain injury show orthostatic intolerance when mobilized on a tilting table, potentially resulting in low mobilization intensity. However, they observed a significant difference in the time to open eyes after the intervention, highlighting the clinical relevance of implementing verticalization safely and with constant monitoring ⁽⁷⁾.

We propose the need to investigate the persistence of changes over time, whether the achieved effect size is modified based on the evolution time, and the addition of multisensory stimuli. These factors should be considered in future research.

Verticality stimuli achieved through sitting are an accessible and safe intervention. Studies with methodological rigor are needed to demonstrate their causal relationship with changes in consciousness, as it could be a useful tool for implementation in routine practice.

Conflict of interest

The authors declare that they have no conflicts of interest

Acknowledgment

Gentile Camila, Aguirre Guadalupe, Gitard Olivia and Rougier Lisandra

We confirmed that the manuscript complies with all instructions to authors.

We confirmed that authorship requirements have been met and the final manuscript was approved by all authors.

Author’s contributions: Gerardo Candoni: Data Collection, Report Database, Validation; Daniela Lecouna: Data Collection, Report Database, Validation; Carolina Troia: Data Collection, Report Database, Validation

We confirmed that this manuscript has not been published elsewhere and is not under consideration by another journal.

We confirmed adherence to ethical guidelines and ethical approvals (IRB).

We don't use a reporting checklist.

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Table 1. Clinical-demographic characteristics
	Subject 1	Subject 2	Subject 3	Subject 4	Subject 5	Subject 6	Subject 7	Subject 8
Sex	M	F	F	F	F	M	M	M
Age	70	78	71	63	83	72	65	73
Injury site	Supratentorial	Both	Both	Supratentorial	Supratentorial	Supratentorial	Supratentorial	Both
Time of evolution	69	29	91	40	35	63	73	16
Tracheostomy	Sí	No	Sí	Sí	Sí	Sí	Sí	No
Feeding	PEG	NT	NT	NT	NT	NT	NT	NT
Craniectomy	Yes	No	No	No	No	Yes	Yes	No
Anticonvulsant	2	1	3	3	0	3	0	2
Complications
Vasospasm	No	No	Sí	No	No	No	No	No
Rebleeding	Yes	No	No	No	No	Yes	No	No
Seizure status	No	No	Yes	Yes	No	Yes	No	No
NA: not available; PEG: Percutaneous Endoscopic Gastrostomy; NT: Nasogastric Tube

Table 2. Assessment of awareness
	Sujeto 1		Sujeto 2		Sujeto 3		Sujeto 4		Sujeto 5		Sujeto 6		Sujeto 7		Sujeto 8
	Inicio	Fin	Inicio	Fin	Inicio	Fin	Inicio	Fin	Inicio	Fin	Inicio	Fin	Inicio	Fin	Inicio	Fin
CRS-R	3	4	8	10	9	15	6	10	13	13	6	8	14		9	12
Subscore
Auditory	1	0	1	1	1	4	1	2	3	1	0	0	1		1	1
Visual	0	1	3	1	3	4	1	3	1	3	1	1	4		3	3
Motor	0	2	2	5	2	4	0	2	5	5	4	4	4		2	2
Oromotor	1	0	0	2	1	1	1	1	0	2	0	1	1		1	2
Communication	0	0	0	0	0	0	0	1	1	1	0	1	1		0	1
Arousal	1	1	2	1	2	2	3	1	3	1	1	1	3		2	3
Level of consciousness	UWS	UWS	MCS	MCS	MCS	MCS	UWS	MCS	MCS	MCS	MCS	MCS	MCS		MCS	MCS
CRS-R: Coma Recovery Scale-Revised; UWS: Unresponsive wakefulness syndrome; MCS: Minimal consciousness state

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Physiotherapeutic Management of a Sitting Program for Subjects with Altered Consciousness: A Case Series

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Abstract

INTRODUCTION

Objective

METHODS

Location and Participants

Intervention

Data Collection

Ethical Aspects

Conceptual and Operational Definition of Variables

RESULTS

DISCUSSION

CONCLUSION

Declarations

Conflict of interest

References

Tables

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