SMART - Recognising the value of existing practice and introducing recent developments: leaving no stone unturned in the assessment and treatment of the PDOC patient.

Abstract

Over the last 25 years there have been a number of papers highlighting the issues of high rates of misdiagnosis in prolonged disorders of consciousness (PDOC) (Andrews, K., Murphy, L., Munday, R., & Littlewood, C. (1996). Misdiagnosis of the vegetative state: Retrospective study in a rehabilitation unit. BMJ, 313(7048), 13-16; Childs, N. L., Mercer, W. N., & Childs, H. W. (1993). Accuracy of diagnosis of persistent vegetative state. Neurology, 43(8), 1465-1467). Surprisingly, these rates still remain at the same level despite defined criteria for diagnosis (Schnakers, C., Vanhaudenhuyse, A., Giacino, J., Ventura, M., Boly, M., Majerus, S.,…Laureys, S. (2009). Diagnostic accuracy of the vegetative and minimally conscious state: Clinical consensus versus standardized neurobehavioral assessment. BMC Neurology, 9(35), 1-5; Van Erp, W., Larvrijsen, J., Vos, P., Bor, H., Laureys, S., & Koopmans, R. (2015). The vegetative state: Prevalence, misdiagnosis and treatment limitations. JAMDA, 85, e9-85.e14. doi: 10.1016/j.jamda.2014.10.014 ). This indicates the continued need for careful standardised assessment by skilled assessors to identify all potential meaningful responses and to establish a correct and incontrovertible diagnosis. The Sensory Modality Assessment and Rehabilitation Technique (SMART) is one of three assessments identified for the assessment of PDOC in the Royal College of Physician guidelines (Royal College of Physicians, 2013). The RCP guidelines and recent publications have highlighted and substantiated the value of some of the existing practices and unique features of the SMART. In recognition of the need to keep SMART current, SMART Version 3 is being developed and will be launched shortly. The interim SMART developments will be introduced in this paper and applied to practice through the illustration of a case study. Evidence suggests that SMART is a current and invaluable tool for the clinical and medico-legal assessment and treatment of the PDOC patient.