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Kelly Betts , PT, DPT, NCS Physical Therapist

Kristen M. Ferguson, M.A. CCC-SLP Speech-Language Pathologist

Disorders of Consciousness:

A Comprehensive Treatment Approach

Disclosure / COI Statement

We have the following relevant relationships in the products or services described, reviewed, evaluated or compared in this presentation.

Relevant Financial Relationship(s)

• TIRR Innovations Grant – Use of the Body Weight Support Treadmill in the Minimally Conscious Patient: Effects on Arousal, the

Cardiopulmonary System, and Response to Multi-Sensory Stimulation

• Principle Investigators: Kelly Betts, PT, DPT and Patrice Perrin, PT, DPT

• TIRR Memorial Hermann Employees – Kelly Betts, PT, DPT, NCS

– Kristen M. Ferguson, M.A. CCC-SLP

Relevant non-financial relationship(s)

• No relevant non-financial relationships to disclose

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Course Objectives

1. Overview of Disorders of Consciousness (DOC)

2. Discuss importance of assessment in this population • Describe the Coma Recovery Scale – Revised (CRS-R) and

its limitations

• Explain the use of Individualized Quantitative Behavior Assessments (IQBAs)

3. Interdisciplinary Goal Planning

4. Interdisciplinary Interventions

5. Discharge Planning

Consciousness

• Conscious behavior is often subtle and inconsistent

in the aftermath of a severe brain injury.

• It must be systematically differentiated from reflexive

or random behaviors

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The Trans-disciplinary Team Approach

• Input from many disciplines regarding patient’s abilities, well-being, and overall care.

• Important to bridge all of the various medical and paramedical disciplines.

• Critical to include the family as part of the team.

• Need multiple observers at different times of day.

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PM&R Physician

Specialized Nursing

Respiratory Therapist

Electrophysiologist

Neuro-Ophthalmologist

Occupational Therapist

Physical Therapist

Speech-Language Pathologist

Clinical Neuropsychologist

Case Manager

Social Worker

Chaplain

Family

Patient

Diagnostic Accuracy

• The literature suggests

that approximately 40%

of patients are

erroneously assigned a

diagnosis of VS.

• Standardized behavioral

assessment is a much

more sensitive means

of establishing a

diagnosis than clinical

consensus. 8

Schnakers et al. BMC Neurology 2009

Standardized Assessment

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Behavioral Assessment

• Behavioral observation constitutes the major tool for

detecting signs of consciousness.

• Distinction between arousal vs. consciousness:

– Arousal is necessary, but insufficient, for

consciousness.

– The repertoire of behaviors available for

assessment of conscious awareness may be

dramatically diminished.

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Neurobehavioral Assessment of Disorders of Consciousness

Scales with acceptable standardized administration

and scoring procedures:

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Coma Recovery Scale-Revised (CRS-R)

Sensory Stimulation Assessment Measure (SSAM)

Wessex Head Injury Matrix (WHIM)

Western Neuro Sensory Stimulation Profile (WNSSP)

Sensory Modality Assessment Technique (SMART)

Disorders of Consciousness Scale (DOCS)

Coma/Near-Coma Scale (CNC)

Moderate reservations

Major reservations

Minor reservations

Coma Recovery Scale – Revised

• The CRS-R was developed

in 1991 and revised in 2004.

• The CRS-R assists with:

– Differential diagnosis.

– Prognostic assessment.

– Treatment planning.

• Contains 23 items that comprise

6 subscales.

• Standardized scoring is based on

the presence or absence of

operationally defined behavioral

responses to specific sensory

stimuli.

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Who is Appropriate?

• Patients who range from Rancho Level II to V:

• Level II: Generalized Response:

– Begin to respond to stimuli but slow, inconsistent, or delayed.

– Responses tend to be similar irrespective of stimulation.

• Level III: Localized Response:

– Increased movements and reacts more specifically to stimuli (e.g., turns toward sound, withdraws from pain).

– May begin to respond inconsistently to commands and yes/no questions.

• Level IV: Confused and Agitated

• Level V: Confused and Inappropriate 13

Coma Recovery Scale-Revised Subscales

Baseline Observation

• Purpose:

– Determine level of arousal.

– Facilitate selection of appropriate commands.

– Help differentiate volitional from random/coincidental movements.

• Observe for one minute and record observations:

– Resting posture of extremities, eye opening status, presence/absence of spontaneous visual fixation or tracking, type/frequency of spontaneous movement.

– If no eye opening, perform the arousal protocol.

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Visual

Function

5: Object Recognition *

4: Object Localization – Reaching *

3: Visual Pursuit *

2: Fixation

1: Visual Startle

0: None

Auditory

Function

4: Consistent Movement to Command *

3: Reproducible Movement to Command *

2: Localization to Sound

1: Auditory Startle

0: None

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Oromotor/Verbal

Function

3: Intelligible Verbalization

2: Vocalization/Oral Movement

1: Oral Reflexive Movement

0: None

Motor

Function

6: Functional Object Use †

5: Automatic Motor Response *

4: Object Manipulation *

3: Localization to Noxious Stimulation *

2: Flexion Withdrawal

1: Abnormal Posturing

0: None/Flaccid

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Arousal

Scale

3: Attention

2: Eye Opening without Stimulation

1: Eye Opening with Stimulation

0: Unarousable

Communication

Scale

2: Functional – Accurate †

1: Non-Functional – Intentional *

0: None

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Limitations and Medical Complications

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Post-traumatic Epilepsy Dysautonomic Storming, tachycardia,

blood pressure changes, fever

Spasticity and Posturing Arousal Deficits

Hydrocephalus Attention Deficits

Tracheostomy and secretion

management

Apraxia

Visual Deficits Aphasia

Hearing Deficits Primary language

Heterotopic Ossification Abulia

Bruxism Pressure sores

Individualized Quantitative Behavioral Assessment (IQBA)

• Due to the variability of this patient

population, individualized

assessments are needed to more

formally assess a patient’s response.

• Complements standard

neurobehavior assessments, such as

the CRS-R

• Advantage is that this address the

particular questions and behaviors of

concern to family members and

clinicians

• Differences in the frequency of the

target behavior can be assessed

statistically to determine if the rate of occurrence is significantly greater in

one condition relative to others.

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IQBA

Command Following Protocol • Establishes a method for consistently and

accurately assessing a patient’s ability to

follow commands.

• General data recording is not sensitive

enough to show if patient is becoming

more consistent over time.

• Ambiguity regarding command-following

responses in DOC patients:

– Voluntary, involuntary, and

reflexive responses.

– Reliability issues (false positive

data recording).

• Important for treatment: a starting point for

communication.

Vision Protocol • Visual functioning is one of many areas

used to assess a patient’s level of

consciousness.

• Clinical questions regarding the status

of the visual system may arise.

• Vision is a critical channel for acquiring

information, especially in the DoC

population because exploring and

manipulating the environment can be

limited.

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Command Following Protocol

• Determine the command

• Setup of IQBA with team collaboration

• Collection of data

• Review of results

• Integrate into treatment plan

VP Methods

• Similar to Command Following Protocol, set-up and assessment are individualized to the particular patient.

• Stimuli:

– Glossy, color, meaningful photo.

– Plain white card the same size as the photo

• Procedure:

– Patient shown unilateral stimulus or bilateral stimuli.

– Yes Response: first lateralized eye movement after presentation.

– No Response: No eye movement within 5 seconds.

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Data Pattern for VP

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Stimulus

(left/right) Looks Left

Looks Right

No Response

1. Photo/____ 9 1 21

2. ____/Photo 1 28 3

3. Card/____ 12 4 16

4. ____/Card 1 12 19

5. Photo/Card 1 25 7

6. Card/Photo 4 19 9

TOTAL 28 89 75

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IQBA Conclusions

• Command Following Protocol and Vision Protocols are examples of IQBAs

• Command-following and vision protocols are aspects used in assessing level of consciousness.

• Command-following is central to ensuring the modality of treatment intervention matches patient’s abilities:

– It can also help to facilitate family members’ understanding of observed behaviors (e.g. volitional versus involuntary/spontaneous)

• Vision protocols assist in helping determine if a patient has gaze preference, field cut, neglect, etc.

• Quantitative data can identify and validate subtle patterns we do not pick up on as clinicians

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Pain Assessment

• Biofeedback

(vitals)

• NCS-R (Chatelle

et al.)

Affective Responding

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Affective Responding

• Often forgotten during assessment but also very powerful.

• Frequently reported by family.

• Environmentally contingent affective responses are a sign of conscious awareness:

– May require an IQBA to assess.

– Standardized neurobehavioral assessments do not quantify this area.

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Therapy Goals

PT/OT Goals

• Assess level of consciousness

• Positioning in wheelchair and bed

• Spasticity Management

• Standing Programs

• Equipment trials

• Establishing a home program

• Initiate intensive mobility program

• Family/Caregiver Training

• Manage medical issues with medical team

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OT/PT Goal Examples

• Positioning Goals:

– Pt will tolerate bed positioning to inhibit abnormal tone, maintain

alignment, and prevent skin breakdown

– Pt will tolerate wheelchair positioning to inhibit abnormal tone,

maintain alignment, and prevent skin breakdown

• Neuromuscular Goals:

– Pt will have increased ROM in ankle via serial casting to improve

alignment in preparation for weight bearing with functional tasks.

– Patient participates in activities to facilitate increased postural

and motor control throughout UEs/LEs/trunk/head in preparation

for participation in functional mobility and ADLs

– Pt will participate in a standing program for…

OT/PT Goal Examples

• Discharge Planning Goals:

– Patient/family will be trained in all aspects of

patient's care,

– Patient/family has necessary equipment and

supplies and/or generated prescriptions prior

to time of discharge.

– Patient will have written and/or verbal home

program prior to discharge.

PT/OT Treatment Options

Pain assessment and management

Spasticity assessment and

management

Head/trunk control

Identifying movement for command

protocols

Surface EMG

Vestibular assessment and

treatment

Positioning programs: bed and w/c

Splinting and Casting for ROM

and/or positioning

Standing program

Trying various positions/activities to

promote increased arousal and

consciousness

Prone, tall kneeling, quadruped,

standing, walking

Responses to multisensory

stimulation

Co-treats with MT and TR to

improve responsiveness

Equipment trials

Caregiver/Family training

Establishing an extensive home

programs and modifying

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Spasticity Management

• Conservative management

– Casting

– Splinting

– w/c and bed positioning

– Stretching

– Inhibitive techniques

• Medical management

– When the above techniques aren’t adequate or are no

longer working

– Oral medications

– Injections/Neurolytics

– Intrathecal Baclofen (ITB) pump

Casting

• Indications for casting:

– Decreased ROM

– To maintain proper alignment

– Reduce motion at joints to counteract effect of

spasticity

– Improve:

• Function

• Hygiene

• Cosmesis

– Skin integrity

Positioning: In Bed

• Goals:

– To maintain neutral alignment

– Minimize the effects of spasticity

– Decrease risk of skin breakdown

• Props: foam, casts/bivalves, splints

• Consider:

– Position: side-lying is considered the most neutral position for spasticity

– How they can be used in more than one position

• They need to roll every 2 hrs

– User friendliness

• Can nursing and/or family implement your program?

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Positioning: In Bed (cont.)

• Specific examples:

– Adductor wedges

– Foam blocks to inhibit extensors spasms of

LEs.

– Pillows between arms and trunk

• If too strong consider foam here as well

– Bivalves vs. PRAFOs vs. custom orthotics

• When to consider ordering custom orthotics

– UE bivalves and splints

Bed Positioning

Bed Positioning

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Positioning

Positioning: In W/C

• Goal: Attempt to achieve neutral midline

alignment while maintaining function

– May not be 100% ideal but what is a good

compromise to allow them to be functional

and prevent skin

breakdown/contracture/compensation.

• Props: lap tray, angle adjustable foot

plates, foam build ups, inserts for trunk or

pelvis, straps

W/C Positioning

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Short term vs. long term

• Short term:

– Foam, straps, bi-valves

• Long term

– Custom orthotics, custom wheelchair

• NOTE: Is their positioning going to change with

spasticity management?

• The patient may not be appropriate for a custom

orthotic if they are receiving Botox or an ITB pump

OT/PT Treatment Options: Proprioceptive Feedback

Developmental positions

• Weight bearing

• Quadruped

• Tall kneeling

• Prone

• Standing

(Co-treats are important)

OT/PT Treatment Options: Electrical Stimulation

• Various uses:

– To prevent atrophy in an acute care setting

• Hirose et al:

– ??30-40mA; 30 min daily; BLEs (flexors and extensors)

– Acute care setting; starting 7 days after admission

– Performed weekly for 6 weeks

– Result: effective in preventing disuse atrophy in pt’s with DOC

– To improve arousal

• Right Median Nerve stimulation:

– Shown to cause earlier arousal from coma

– Inconsistently shown to improve functional and cognitive outcomes

– Cossu 2014

• FES

– Decreases spasticity

– Prevent muscle atrophy

– Provides sensory input

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OT/PT Treatment Options: Standing Program

• Elliott L, Coleman M, Shiel A, et al.

demonstrated Improvement in behavioral

responses in those in vegetative and

minimally conscious states.

• Study states that patient experienced

increased arousal at 85 degrees on a tilt

table vs. supine in bed

– Great reason to co-treat with SLP

OT/PT Treatment Options: Ambulation

• Progression from standing

• Automatic motor activity, thus may see:

– Increased arousal

– Increased muscle activation

– Improved responsiveness to stimuli

• No literature present on use of ambulation in

those with DOC, though is seems a natural

progression from a standing program

• Con: difficult and labor intensive; maintaining

safety while optimizing movement patterns

OT/PT Treatment Options: Body Weight Supported Treadmill Training (BWSTT)

• Benefits:

– Increased repetition of a task-specific activity (motor planning principles)

– Earlier opportunities for weight bearing

– Improve strength

– Reduce spasticity

– Decreased burden on therapist; allowing for focus to be on facilitating various components of gait

• Improve safety when working with those with significant functional impairment

• Allows for improve safety and mechanics when ambulating with the DOC population

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OT/PT Treatment Options: BWSTT (cont)

• VERY limited evidence when studied in the TBI population with inconsistent reports in it’s efficacy

• Lapitskaya, Nielsen, Fuglsang-Frederiksen (2011) – No changes in EEG following robotic gait training in pts with

severe TBI

– Might be an indicator of the severity of the brain injury/dysfunction

• In case studies with TBI, it has shown: – Improve cardiorespiratory capacity

– Improve efficiency of gait

– Increase gait speed

– Decrease use of assistive devices

• Supported in the literature in the those with SCI and CVA (Tefertiller et al 2011)

OT/PT Treatment Options: BWSTT (cont.)

• Research has demonstrated that it is not superior to standard gait/over-ground training

– However, it is shown to be an effective treatment modality

• This suggests it should be used in a progression:

– Transitioning from BWS/robotic gait training to traditional over-ground training as is safe and effective

– Use those clinical reasoning skills: to optimize gait mechanics, weight bearing, repetitions

– Progress from a more restrictive environment to a less restrictive environment when appropriate

OT/PT Treatment Options: BWSTT (cont)

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Caregiver Training

• Importance

– Almost all caregivers of a study stressed the

importance of being informed about their

relatives’ health condition, being able to take

care of them, being involved in decisions that

affect their relatives and easily communicating

with operators of the treating team

(Leonardi, 2012)

Caregiver Considerations

• Interventions should be aimed at minimizing caregiver

burden and developing individualized disability

management programs.

• Therapists working with this patient population should

consider the needs of the individual patient in the

context of their family/care environment and recognize

ease of care-giver burden as a meaningful outcome.

(Wheatley-Smith, 2013)

Caregiver Considerations

• As care-giving is a long-term commitment process, support to the caregiver should be guaranteed throughout the duration of the relative’s disease

• Early involvement of caregivers in a comprehensive process of care should be guaranteed by healthcare supporting programs (Giovannetti, 2012)

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Equipment

• Things to consider ordering:

– Hospital Bed and Mattress (Group 1 and 2)

– Tilt in space w/c and cushion

– Hoyer lift with slings

– Ramps

– Tilt in space shower chair

– Inflatable tub

– Orthotics (solid vs articulated)

– Standers

SLP Goals

•Assess level of consciousness

•Auditory Comprehension

•Verbal Expression and Voice

•Swallowing & Secretion Management

•Attention/Arousal

•Family/Caregiver training and home program

•Manage medical issues with medical team

SLP Goals - Inpatient

• Goals for first 2 weeks (geared more toward the

inpatient setting) – Oral Care Training

– Passive oral motor exercises/swallowing via TTS using lemon

swabs

– Trach Management PMV/Trach cap toleration

– Voicing

– Attend to environmental stimuli

– Understand patient’s visual perceptual ability

– Identify best communication modality for yes/no response

– Possible MBSS if indicated or FEES to assess how patient

is managing secretions and possible PO trial tolerance.

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SLP Goals -Inpatient/Outpatient

• Auditory Comprehension

– Patient will follow 1-step simple commands with 30-50%

accuracy with max cues.

– Patient will establish consistent yes/no communication system

• Verbal Expression

– Patient will voice to command 1-3 times in a 60-minute session

with max cues.

• General Health

– Complete instrumental swallow assessment as appropriate

(FEES/MBSS)

– PMV/Trach occlusion trials

• Attention

– Patient will maintain eye opening for a 60-minute session over 3

consecutive sessions.

SLP Example Goals

• Comprehension/CRS-R Auditory Function

– Long Term Goal:

• Patient will demonstrate consistent movement to

commands.

– Short Term Goals:

• Patient will demonstrate localized response to

auditory stimulation with____ % accuracy given

max cues.

• Patient will follow 1-step commands with ___%

accuracy per session with max cues.

SLP Example Goals

• Comprehension/CRS-R Motor Function – Long Term Goal:

• Patient will demonstrate functional object use.*

– Short Term Goals:

• Patient will respond to/follow 1-step commands with ___%

accuracy per session with max cues.

– Long Term Goal:

• Patient will demonstrate functional communication.*

– Short Term Goals:

• Patient will establish yes/no communication modality with

_________ given max cues and modeling.

• Patient will answer egocentric yes/no questions using

establish yes/no communication modality with ___%

accuracy with max cues.

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SLP Example Goals

• Comprehension/CRS-R Communication – Long Term Goal:

• Patient will demonstrate functional communication.* (via

verbalizations, UE and LE movements, eye gaze, etc.)

– Short Term Goals:

• Patient will answer yes/no egocentric questions with %

accuracy with max cues.

SLP Example Goals

• Expression/CRS-R: Oromotor/Verbal

Function – Long Term Goal:

• Patient will produce intelligible verbalizations for

communication.

– Short Term Goals:

• Patient will demonstrate non-meaningful vocalization with

% accuracy in response to pain/discomfort.

SLP Example Goals

• General Health & Dysphagia/CRS-R:

Oromotor – Long Term Goal:

• Patient will demonstrate reflexive and/or volitional swallow.

• Patient will tolerate PO trials and/or PO diet without s/s of

aspiration.

– Short Term Goals:

• Patient will tolerate oral care via suction swab/suction

toothbrush/standard toothbrush with (min/mod/max) cues for

mouth opening.

• Patient will elicit 10 swallows per 30-minute session using

thermal tactile stimulation and PO trials of ice chips.

• Patient will participate in objective swallow assessment

(FEES and/or MBSS) to determine appropriate consistency

for PO trials.

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SLP Example Goals

• Attention/CRS-R: Visual Function – Long Term Goal:

• Patient will demonstrate object recognition.

– Short Term Goals:

• Patient will follow stimuli visually through left and right visual

fields with % accuracy given max cues in a given

session.

SLP Example Goals

• Attention/CRS-R: Arousal – Long Term Goal:

• Eye opening without stimulation and attention

– Short Term Goals:

• Patient will maintain eye opening for ____ minutes in a given

session with max cues.

• Patient will track visual stimuli in 3 out of 4 trials with max

cues

SLP Example Goals

• Education and Discharge Planning Goals: – Long Term Goal:

• Educate family regarding SLP plan of care

• Patient and/or family will be trained in all aspects of patient’s

care.

• Patient will have written and/or verbal home program prior to

discharge.

– Short Term Goals:

• Utilize quantitative data from visual and command following

IQBA protocols to educate family regarding incidental vs.

intentional behaviors.

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SLP Treatment Options

• Assess level of consciousness via CRS-R bi-weekly with therapy team (PT/SLP and

NP/OT).

• Sensory Stimulation Program

– Auditory stimulation

– Visual Stimulation

– Olfactory Stimulation

– Tactile Stimulation

– Gustatory Stimulation

• Assess swallow function via FEES and/or MBSS for secretion management

• Oral care via suction kits

• Trach care and speaking valve

• Treatment for voicing/verbalizations for functional communication

• Develop consistent command following using IQBA’s

• Develop communication modality via low tech and/or high tech AAC system

• Attend to environmental stimuli

• Co-treatments with PT/OT/MT

• Family training and education

Discharge Planning

• Skilled Nursing Facility vs. Home Health vs. Outpatient

• Appropriate time to discharge

– Medically stable

– Can move on to next level of care

• Often met with resistance (see as giving up)

– Setting clear expectations from the beginning

– Giving family clear expectations from OP

– Giving family goals to work on at home that if pt

meets/progressed then they can set-up a time to be re-evaluated

again for either IP or OP

• Working with Social Worker and Case Manager to help

with realistic length of stay goals

References

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