Introduction:
The assessment of consciousness in patients who have sustained a severe brain injury in the intensive care unit (ICU) poses a significant challenge. Covert consciousness refers to a state where patients exhibit no overt signs of behavioral responsiveness, yet their brain activity – as indexed through functional neuroimaging - demonstrates preserved awareness and cognitive function. In the ICU setting, accurately identifying such cases is crucial for appropriate patient care and medical decision-making. Functional near-infrared spectroscopy (fNIRS) is a promising modality for measuring and mapping brain function, as it is portable and can be safely used at the bedside This study explores the feasibility of using fNIRS to detect covert consciousness in patients with acute brain injury in the ICU.

Methods:
16 behaviorally unresponsive ICU patients with varying brain injury etiology were enrolled. Patients were asked to imagine playing a game of tennis while undergoing fNIRS monitoring. The fNIRS technique enables the measurement of cerebral hemodynamic changes associated with cognitive processes, providing a window into the neural activity underlying motor imagery. 24 age and sex-matched healthy controls were also enrolled. The fNIRS setup consisted of a 129-channel NIRScoutXP system. A channel was considered activated if there was a significant increase in oxyhemoglobin and a concurrent decrease in deoxyhemoglobin (p<0.05).

Results:
Of the 16 patients tested, two demonstrated the ability to follow commands during the motor imagery task despite the absence of observable signs of behavioral consciousness. Analysis of the fNIRS data revealed distinct patterns of neural activation during the motor imagery task in both patients and healthy controls. These findings were supported by positive responses to a language comprehension task.

Discussion:
This study highlights the capability and feasibility of fNIRS to detect convert consciousness in patients who appear behaviourally non-responsive in the ICU. The results underscore the need for more nuanced and sensitive approaches to consciousness assessment in critical care settings. Further research and validation of fNIRS as a tool for detecting covert consciousness could revolutionize our understanding of patient awareness in the ICU, impacting treatment decisions and enhancing patient care strategies.

Patients with disorders of consciousness (DoC) such as the minimally conscious state (MCS) and the unresponsive wakefulness syndrome (UWS) are a challenging population lacking effective treatment options. Among neuromodulation techniques, trans-auricular vagal nerve stimulation (taVNS) may act non-invasively through a bottom-up manner to modulate thalamo-cortical connectivity and promote the recovery of consciousness in the acute phase of severe cerebral damage. In this clinical trial, we aim to characterize the clinical short and long-term effects of taVNS in patients with DoC and determine the phenotype of clinical responders.
Methods: We are conducting the first randomized placebo-controlled double-blind clinical trial assessing the effects of taVNS in 44 acute to sub-acute DoC patients. In this study, patients randomly receive either 5 days of active bilateral vagal stimulation for 45 minutes a day (3mA; 200-300μs current width, 25Hz) or sham stimulation. Behavioural measures (Coma Recovery Scale-Revised, CRS-R) are collected twice at baseline as well as at the end of the treatment. Moreover, patients’ long-term evolution at 3 months after the end of the treatment period is assessed through phone-adapted outcome measures performed with family or caregivers (Glasgow Outcome Scale - Extended, GOS-E; Disability Rating Scale, DRS).

BACKGROUND: The quality and quantity of evidence varies widely across different aspects of Moderate to Severe Traumatic Brain Injury (MSTBI) Rehabilitation research. There is a notable lack of published research evidence to inform evidence-based recommendations. This is especially prominent in the new and emerging areas of rehabilitation, such as Telehealth and Intimacy and Sexuality. The Canadian Clinical Practice Guideline for the Rehabilitation of Adults with Moderate to Severe Traumatic Brain Injury addresses this gap following a robust living update process that consists of ongoing identification of research literature, expert panel review, rigorous evaluation of evidence quality and achieving clinical consensus in consultation with persons with lived experience (PWLE) to develop and modify current evidence-based recommendations in the areas that lack published research.

METHODS: A rigorous multi-component guideline review process was developed and refined to ensure that recommendations reflect the rapidly emerging evidence and address the priorities identified by end users and people with lived experience.

1) Systematic review of published MSTBI evidence
2) Priorities identified by PWLE of MSTBI and guideline end users through surveys and focus groups
3) Diverse interdisciplinary expert panels that include PWLE
4) Online and offline review of the current published evidence, clinical and lived experience
5) Rigorous grading of available evidence
6) Expert panel voting to achieve a minimum of 75% by 80% of the expert panel

RESULTS: Since 2015, this review process has yielded 351 recommendations divided into 21 chapters focusing on different domains of MSTBI rehabilitation. Currently, the Guideline includes 239 Consensus-based recommendations which comprise 68% of the Guideline. Two new sections were added in 2022/23: Telerehabilitation - 14 recommendations including 11 (79%) consensus-based and Intimacy and Sexuality - 10 recommendations including 9 (90%) consensus-based. Recommendations were added that responded to PWLE comments that the guideline did not stress the importance of continuing rehabilitation into the community through participation in daily activities and promoting hope for ongoing improvements. Focus has also been on developing algorithms and tools to facilitate implementation.

CONCLUSIONS: This comprehensive TBI rehabilitation guideline uses a transparent and methodologically robust review process that integrates knowledge and experience of diverse interdisciplinary expert panels including the people with lived experience of MSTBI. This process allows the development of high-quality recommendations in the priority areas where published evidence is currently lacking. Including consensus-based recommendations and tools helps ensure that the guideline contains all relevant, current and critically evaluated recommendations that integrate the new areas of rehabilitation and incorporate the needs, values and preferences of PWLE.

Background: The Canadian Clinical Practice Guideline (CPG) for the Rehabilitation of Adults with Moderate to Severe Traumatic Brain Injury (TBI) helps inform TBI care across jurisdictions through its ongoing and comprehensive review of research and clinical evidence. This review helps the CPG produce best-practice recommendations to improve the quality and consistency of care provided by healthcare professionals, as well as patient health outcomes. The CPG’s beneficial effects, however, are contingent on not only a methodologically rigorous guideline development process, but also on the successful knowledge translation (KT) and implementation of the resulting recommendations and associated tools.

Objectives: Orient healthcare professionals to the CPG and help 1) increase understanding of the clinical value and utility of the living CPG and Ideal Care Pathways, which promote quality care and equity of access across the care continuum, and 2) guide implementation of the up-to-date best-practice recommendations, resources, and clinical tools.

Methods: Regulated Health Professional Associations in Ontario, Canada were approached to partner in and co-develop targeted KT activities rooted in the principles of adult learning: 1) self-concept; evidenced in CPG KT’s self-directed, asynchronous learning model, 2) adult learner experience, readiness to learn, orientation to learning, and motivation to learn; evidenced in CPG KT’s target audience and voluntary attendance, and 3) active learning; evidenced in CPG KT’s real-life case examples presented by healthcare professionals and interactive discussion. The KT activities promoted the relevance of the CPG by using clinical data, partnering with relevant practicing clinicians, and addressing current clinical issues in TBI care. The primary target audience was healthcare professionals who may not routinely encounter individuals who have sustained a TBI, and/or who may not be up to date on TBI best care practices.

Results: The most popular KT method was interactive webinars, but in many cases, multiple methods, including newsletter articles, blog posts, website links and all-member emails, were used. All webinars were recorded, and their slide decks were made available for asynchronous learning. The KT activities have been ongoing since June 2023, and have shown excellent engagement as evidenced in the increasing number of visits to the CPG website, with 7700 visits in July 2023 to 9205 visits in September 2023. Invitations have been forth coming to return for further interactive sessions and to present at relevant RHP conferences. Further data on the CPG KT engagement, follow-up activities, and Google Analytics for the online resources will be presented.

Conclusion: Our multi-faceted and collaborative KT strategy for the CPG and Ideal Care Pathways is key in helping healthcare professionals make informed TBI clinical care decisions based on the most up-to-date scientific evidence for quality care, supporting the overall vision to provide ideal and equitable lifelong care for ALL after a brain injury.

Disorders of consciousness after severe brain injury encompass conditions of coma, vegetative state/unresponsive wakefulness syndrome, and minimally conscious state. DoC clinical presentation pose perplexing challenges to medical professionals, researchers, and families alike. The outcome is uncertain in the first weeks to months after a brain injury, with
families and medical providers often making important decisions that require certainty. Prognostication for individuals with these conditions has been the subject of intense scientific investigation that continues to strive for valid prognostic indicators and algorithms for predicting recovery of consciousness. This manuscript aims to provide an overview of the current clinical landscape surrounding prognosis and optimizing recovery in DoC and the current and future research that could improve prognostic accuracy after severe brain injury. Improved understanding of these factors will aid healthcare professionals in providing optimal care, fostering hope, and advocting for ethical practices in the management of individuals with DoC.