Neurology

Editors' note: Practice guideline update recommendations summary: Disorders of consciousness: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology; the American Congress of Rehabilitation Medicine; and the National Institute on Disability, Independent Living, and Rehabilitation Research

In their American Academy of Neurology (AAN) practice parameter, Giacino et al. provided a thorough review of the available evidence pertaining to the care of patients with impaired consciousness. The expert panel provided level of recommendations (LORs) regarding the discussion of long-term care needs, pain management strategies, and techniques for neuroprognostication in patients with disorders of consciousness. In response to these consensus recommendations, Phan et al. highlight 1 potential limitation of the LOR classification system that was used. Historically, the highest LOR (level A) was afforded only to recommendations based on 1 or more randomized clinical trials. However, this requirement was amended by the Institute of Medicine in 2011 as well as the 2011 AAN Clinical Guideline Practice Manual, as the authors emphasize in their response. After 2011, a level A recommendation was permitted as long as there was strong and consistent related evidence and inferences could be drawn. Therefore, a higher LOR could be assigned to recommendations with less explicit substantiation from large randomized clinical trials. By using this classification schema, some recommendations may be generalized to patients who are likely to benefit from such guidance.

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