Intact for internal states and external events, but often does not lead to functional behavior because of disorganization, misinterpretation, etcĪbility to communicate generally intact, but social appropriateness and accuracy vary Some cognitive function can be discerned from command following, communication, etc, but fluctuation makes this difficult to assessĬontingent emotional response to family or familiar stimuliįunctional communication–yes and no responses are accurate and reliable, appropriate functional object use of at least 2 common objects Inaccurate or inconsistent yes/no responses, if present Visual fixation, localization to noxious stimulation, intelligible verbalizations, yes/no responses even if inaccurate, reproducible movement to command Present, but sleep disturbance and fluctuating arousal common While eye opening is commonly accepted as indicating transition from coma to VS, there is no consistent evidence that this transition is associated with an improved level of consciousness. List of abbreviations: CAP ( Confusion Assessment Protocol), DRS-98 ( Disability Rating Scale-Revised 98), DSM-5 ( Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition)), MCS ( minimally conscious state), PTA ( posttraumatic amnesia), PTCS ( posttraumatic confusional state), TBI ( traumatic brain injury), VS ( vegetative state) Key research goals are establishment of cutoffs on assessment instruments and determination of levels of behavioral function that distinguish persons in PTCS from those who have emerged to the period of continued recovery. The lower boundary distinguishes PTCS from the minimally conscious state, while upper boundary is marked by significant improvement in the 4 core and 5 associated features. Associated neurobehavioral features include emotional and behavioral disturbances, sleep-wake cycle disturbance, delusions, perceptual disturbances, and confabulation. Core neurobehavioral features include disturbances of attention, orientation, and memory as well as excessive fluctuation. The case definition provides detailed description of PTCS (1) core neurobehavioral features, (2) associated neurobehavioral features, (3) functional implications, (4) exclusion criteria, (5) lower boundary, and (6) criteria for emergence. Consensus was reached through teleconferences, face-to-face meetings, and 3 rounds of modified Delphi voting. The workgroup reviewed 2466 abstracts and extracted evidence from 44 articles. The case definition was informed by an exhaustive literature review and expert opinion of workgroup members from multiple disciplines. This project was completed by the Confusion Workgroup of the American Congress of Rehabilitation Medicine Brain Injury Interdisciplinary Special Interest group. In response to the need to better define the natural history of emerging consciousness after traumatic brain injury and to better describe the characteristics of the condition commonly labeled posttraumatic amnesia, a case definition and diagnostic criteria for the posttraumatic confusional state (PTCS) were developed.
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