Disorders of Consciousness Management in Outpatient Setting

Disclosure Statement

Kirstine Carter, Ph.D.

Alyssa Kelly, MA, CCC-SLP

Kimberly Larriviere, OTR/L

Margaret McKinney, PT, DPT

• Financial – No financial disclosures.

• Non-Financial – Employees of TIRR Memorial Hermann.

Receive no compensation for speaking/presenting on the

topic of DoC. Have no relevant relationship with products

or services describe, reviewed, or compared in this

presentation.

Objectives

• Provide an overview of Disorders of

Consciousness (DoC)

• Understand the role of outpatient

transdisciplinary team as critical part of

continuum of care for patients with DoC

• Understand program development for

outpatient setting for patients with

Disorders of Consciousness

Arousal vs. Awareness

Kothari, S., Gilbert-Baffoe, E., & O’Brien, K.A. (2018). Disorders of Consciousness. In Eapen & Cifu (Eds.),

Rehabilitation After Traumatic Brain Injury (pp. pages of chapter). Location: Publisher.

AROUSAL AWARENESS

COMA - -

VEGETATIVE STATE

(VS)

+/++ -

MINIMALLY

CONSCIOUS STATE

(MCS)

+/++ +

EMERGED FROM

MCS

++ ++

Arousal vs. Awareness

• Arousal – level of consciousness

• Awareness – content of consciousness

• MUST have arousal before someone can

demonstrate awareness

Laureys, S., Boly, M., Moonen, G., and Maquet, P. (2009). Coma. Encyclopedia of neuroscience, 2, 1133-1143.

Definition of DoC

Courtesy of Dr. Kothari

DEATH LIFE

UNCONSCIOUSNESS

COMA VEGETATIVE STATE

CONSCIOUSNESS

MINIMALLY CONSCIOUS STATE

CONSCIOUS

Behaviors in Vegetative State and MCS

Kothari, S., Gilbert-Baffoe, E., & O’Brien, K.A. (2018). Disorders of Consciousness. In Eapen & Cifu (Eds.), Rehabilitation After Traumatic Brain Injury

(pp. pages of chapter). Location: Publisher.

Big Picture: Quick Glance

• Eyes closed, no sleep wake: comatose

• Eyes open, sleep wake: vegetative or

unresponsive wakefulness (UWS)

• Eyes open, inconsistent awareness of

environment and/or self: minimally conscious

(MCS)

• Eyes open, aware of environment and/or self:

emerged

Assessment of DoC

• 40% of pts diagnosed with Vegetative State

were discovered to be conscious with

standardized behavioral measures (Schnakers, et. Al, 2009)

• A long-term survival study of adult trauma

patients found that patient’s discharged to a

skilled nursing facility were 34% more likely to

die 3 years post-TBI than those discharged to

home or to rehabilitation facilities (Davidson, et. al, 2011)

Assessment of DoC

• Behavioral measures are gold standard

– Coma Recovery Scale-Revised (CRS-R )

– Individualized Quantitative Behavioral

Assessment (IQBA)

• Require training and frequent repetition

• Can help identify how to structure your treatment

Day, K.B., DiNapoli, M.V., Whyte, J. (2017). Detecting early recovery of consciousness: A comparison of methods. Neuropsychology Rehabilitation, Apr 7 (1-

9). doi: 10.1080/09602011.2017.1309322.

Factors Masking Consciousness

• Hypoarousal

• Medical (medications, hydrocephalus,

infection)

• Spasticity and contracture

• Environment

• Apraxia

• Attention span

• Impaired sleep-wake cycles

• Neuromuscular impairments including

strength deficits, visual deficits, auditory

deficits, etc.

*These are potential factors that

should be considered during

evaluation and treatment*

Giacino, J.T., Schnakers, C., Rodriguez-Moreno, D., Kalmar, K., Schiff, N., Hirsch, J. (2009). Behavioral assessment in patients with

disorders of consciousness: Gold standard or fool’s gold?. Progress in Brain Research, 177, 63-72.

https://doi.org/10.1016/S0079-6123(09)17704-X

https://doi.org/10.1016/S0079-6123(09)17704-X

Transition to Outpatient

Outpatient Setting-Evaluation

DoC specific medical background

• Date of injury, type of injury (traumatic vs non-

traumatic, anoxic?), time since injury

• Inpatient stay? Identify if CRS-R testing was

done and use results to guide evaluation

• Communication system?

• Family/caregiver report of current behaviors,

videos if possible

Ontario Neurotrauma Foundation. (2016, October). Clinical practice guideline for the rehabilitation of adults with moderate to severe tbi: Section I: Assessment

and rehabilitation of brain injury Sequelae [Data file]. Retrieved from

https://braininjuryguidelines.org/modtosevere/fileadmin/Guidelines_components/Rec/Section_2_REC_complete_ENG_final.pdf


Outpatient Setting-Evaluation

DoC specific medical background

• Medication review

- Depressants

- Stimulants? Trialed stimulants? Timing of

stimulants

• Arousal throughout the day

• Sleep-wake cycles

C., Rosella, Placido B.,Savatore Calabro, R., (2013). Pharmacotherapy for disorders of consciousness: Are ‘awakening’ drugs really a possibility?.

Drugs, 73(17), 1849–1862.

Outpatient Setting-Examination

Non-DoC specific• Vitals - Tracheostomy Management, Pulmonary Care, Secretion Management

• Bladder and Bowel management

• Oral and Dental Hygiene

• Spasticity (Modified Ashworth Scale and Tardieu) – Intrathecal Baclofen Pump (ITB)

• Joint Movement and Range of Motion Exercise – Posture and Position

• Mobility Management – Transfers, Bed Mobility, Head Control

• Prevention of Secondary Complications – Skin breakdown, Nutrition, Deep Vein

Thrombosis

• Equipment and Orthotics

• Adaptive Technology and Environmental Management

• Communication – Established System, Responding to Yes/No questions

• Family Support – Counseling and Training

Klingshirn, H., Grill, E., Bender, A, Strobl, R., Mittrach, R., Braitmayer, K., Muller, M., (2015). Quality of evidence of rehabilitation interventions in longterm care

for people with severe disorders of consciousness after brain injury: A systematic review. J Rehabil Med, 47, 577-585.

Outpatient Setting-Examination

• According to Elliott, Coleman, and Shiel (2005, p. 299) “positional

changes may have a significant impact on behaviours in vegetative

and minimally conscious patients.”

• Determine the following in a variety of positions and with different

stimuli:

– Are they aroused?

– Do they move? reflexive, spontaneous, repetitive, to command *

(against gravity or gravity eliminated)

– Do they respond to auditory input?

– Do they respond to visual input?

– Do they vocalize?

Remember to keep in mind what you have learned

about their PMH, area of injury and how this may

impact their success at demonstrating these things

Goal Setting

• Collaborative goal setting between family,

therapists, physician, and neuropsychologist

• Determine what primary goal is for this patient

and this phase of therapy

– Establishing consciousness, communication,

or is it more of caregiver training, HEP, etc.

Giancino, J.T., Douglas, I., Katz, D.I., Schiff, N.D., Whyte, J., Ashman, E.J., Ashwal, S., Barbano, R., Hammond, F.M.,

Laureys, S., Ling, G.S.F., Nakase-Richardson, R., Seel, R.T., Yablon, S., Getchius, T.S.D., Gronseth, G.S., Armstrong,

M.J. (2018) Practice guideline update recommendations summary: Disorders of consciousness. Neurology, 91, 1-11. doi:

10.1212/WNL.0000000000005926

Sample Goals

• Samples:

– Consistency of command following

– Visual tracking

– Head control

– Seated balance

– Standing tolerance

– Swallowing

– HEP

• MUST discuss goals with other disciplines to prevent

goal replication

*Refer to Sample OT Goals for examples

Assessment in Outpatient: IQBA

• Emphasis on behavioral assessment in treatment of DoC

clients (Giacino et. al., 2018)

• IQBAs can be created in the OP setting with Neuropsychology

• IQBA may detect command following quicker than CRS-R

(Day, DiNapoli & Whyte, 2017)

• More practical than CRS-R in this setting

• Reasons to use:

– Used when behavior is ambiguous to see if it can be use

for a communication system

– Used during medication trials for pre- and post-data

• VERY objective, requires consistency with administrators and

instruction language


• Development of IQBA, as a team decide:

(1.) Session administration variables such as patient positioning,

stimulation to maximize alertness, preliminary range of motion

exercises to facilitate motor responding

(2.) The commands to be given, the number to be administered, the

manner of administration, and the random order within a particular

session

(3.) The operational definition of a response and a format for

recording responses

(4.) Control conditions to minimize the influence of coincidental and

reflexive responding.

(Whyte, DiPasquale & Vaccaro, 1999)


• Importance of multidisciplinary team

• Involvement of caregivers

• Clinical uses of IQBA in outpatient

– Determine if client is following commands

– Assist in development of communication

system

– Can track progress of recovery and response

to treatment

Integrating Behavioral Measures for Treatment

• It is ideal to use what you have observed

on standardized, behavioral measures in

your interventions.

– For example, if patient A does not respond to

visual stimuli, it may be appropriate to target

interventions using auditory input rather than

visual input.

Decision Tree

Treatment Interventions

Sessions to target:

• Impaired arousal and/or consciousness

- Neurostimulating positions and interventions

• ROM restrictions and or spasticity/hypertonicity

impairing wheelchair or bed positioning

- Serial casting, splinting

- Wheelchair set up or positioning; positioning programs

• Command following

• Home exercise program and family training

Wilson, B.A., Dhamapurkar, S., & Rose, A. (2016). Assessment and treatment of people with a disorder of consciousness: An account of some recent

studies. Psychology & Neuroscience, 9(2), 221–229.

Neurostimulating Interventions

• Using consistent

commands across

disciplines and tracking

responses and arousal in

sessions

• Commands should be

mixed with counter-

commands, silence and

enough time for the pt to

respond

Get creative!

Home Exercise Program (HEP)

• Arousal

• Standing programs

• Range of motion

exercises

• Orthotics wear schedule

• IQBA Family could

implement IQBA if

applicable

Seel, R.T., Douglas, J., Dennison, A.C., Heaner, S., Farris, K., Rogers, C. (2013). Specialized early treatment for persons with disorders of

consciousness: Program components and outcomes. Arch Phys Med Rehabil, 94(10), 1908-23.

Things to Consider

• Use of equipment and technology:

– Switches, e-stim, FES bike, litegait, sEMG

• Communication with MD:

– Medication trials, lumbar puncture, sleep study, ITB

pump

• Barriers and/or facilitators:

– Time of day, caregiver support, resources, endurance

for activity, order of therapy, expectations for therapy

Ontario Neurotrauma Foundation. (2016, October). Clinical practice guideline for the rehabilitation of adults with moderate to severe tbi: Section II :

Assessment and rehabilitation of brain injury Sequelae [Data file]. Retrieved from



Discharge

• Giving clear HEP tailored to level of

consciousness

• Expectations of when to return to therapy or

return to MD

– Consciousness change

– Traditional therapy needed (bracing,

equipment, HEP update, etc.)

– Change in status that opens up new goals for

rehabilitationAmerican Speech-Language Hearing Association (n.d.). Documentation in healthcare. Retrieved from

https://www.asha.org/PRPSpecificTopic.aspx?folderid=8589935365&section=Key_Issues


Outpatient Program Creation

Summer 2017- Present

• Fall 2017:

– Creation of primary inter-disciplinary team

– Meeting with inpatient, outpatient medical and

outpatient staff

• Winter/Spring 2018:

– Training modules for all staff and BI-specific

(4 modules)

– Journal Clubs with inpatient team

Outpatient Program Creation

• Spring/Summer 2018:

– Lunch meetings with primary OP team and

monthly meetings with IP team

– First referral Spring 2018

• Summer/Fall 2018:

– Additional patients admitted to program

– Competency for OP BI Team for DoC

– Monthly/bi-monthly rounding

Potential barriers in OP

• Insurance limitations

• Staff education (specialized group)

• Communication between staff

• Scheduling

• Family and caregiver support and abilities

• Design of HEP and Plan of Care (POC)

• Measuring of Progress, Outcome measures

• Transportation

• Fatigue

Case Study- LE

• OP Community referral for OPMC, PT/OT/SLP evaluations on

2/9/18

• Patient background information:

– GSW in 11/4/15 followed by anoxic injury 11/8/15 from

cardiopulmonary arrest

– Inpatient rehabilitation 4/25/16 for 1 month and had short follow-

up of home health

– Pt with very supportive family and living with mother and father,

2 children who his mother observed interacting with

grunting/clicking noises, not performing movements

spontaneously or to command. HEP including standing in

stander, B UE and B LE stretches

– Family goals- communication system, walk and talk

– Medicaid required authorization

Case Study- LE

• Initial Evaluation:

– PT – total A for all mobility, 10 sec head control when placed in position,

moro reflex

• Initial PT goals: HEP, maintain head control for 30 seconds,

caregiver safety of transfer

– OT – total A for all Activities of Daily Living, flexor synergy positioning of

Bilateral Upper Extremities

• Initial OT goals: HEP, donning positioning devices

– SLP – NPO, groaned in response to non-preferred action, localization of

sound reported but not observed at evaluation

• Initial SLP goals: HEP, demonstrate localized response to auditory

stimulation, vocalize in response to pain/discomfort, follow stimuli

through left and right visual fields, elicit a swallow with thermal

tactile stimulation

• Initial Authorization Visit Count: PT (8), OT (4), SLP (8)

Case Study – LE

• Action Steps

– Contacted physician to schedule sleep study

– Discussed medication trials

– Discussed sitting schedule to be up more

during the day

– Coordinated scheduling of Lumbar Puncture

for possible hydrocephalus

Case Study- LE

• Treatment: started 4/3/18

– Coordination with PT, OT, SLP of observations of arousal, reflexive and

spontaneous movement

– Trialed variety of stimulation

• Auditory- music, family voices

• Visual- pictures of children, familiar objects, mirror

• Tactile- e-stim, different surfaces, oral stimulation

• Vestibular- rocking in tilting in space wheelchair, standing, prone,

seated positions

– Creation of IQBA for pt for tracking in session and as HEP

• Tracking behavior in and out of session

• Pre- and post-medical intervention

– Family training for IQBA and HEP

– Pt discharged due to transportation and to return to OP services when

mother retires and following possible shunt surgery.

Case Study- LE Results

• Family subjective perceived improvement:

improvement in arousal, increased in

vocalizations with family

• Unable to establish a communication system

• Inadequate OT goal writing led to decreased

authorized visits as compared to SLP and PT

• Importance of family training

Areas for Program Growth & Improvement

• Involve Neuropsychology from the

beginning

• Improved rounding and handoffs

• Improved goal writing and documentation

• Referrals from other sources

• Continuum of care, transitioning between

settings

References

1. American Speech-Language Hearing Association (n.d.). Documentation in healthcare. Retrieved from


2. Betts, K. & Cheng, V. (2018). Disorders of consciousness: A comprehensive treatment approach. [PowerPoint slides]. TIRR Memorial Hermann:

Rehabilitation & Research, Houston, Texas.

3. Davidson, G.H., Hamlat, C.A., Rivara, F.P., Koepsell, T.D., Jurkovich, G.J., Arbabi, S. (2011). Long-term survival of adult trauma patients. JAMA, 305, 1001-

1007.

4. Day, K.B., DiNapoli, M.V., Whyte, J. (2017). Detecting early recovery of consciousness: A comparison of methods. Neuropsychology Rehabilitation, Apr 7 (1-

9). doi: 10.1080/09602011.2017.1309322.

5. Elliott, L., Colemen, M., Shiel, A (2005). Effect of posture on levels of arousal and awareness in vegetative and minimally conscious state patients: a

preliminary investigation. J Neurol Neurosurg Psychiatry, 76, 298-299.

6. Giancino, J.T., Douglas, I., Katz, D.I., Schiff, N.D., Whyte, J., Ashman, E.J., Ashwal, S., Barbano, R., Hammond, F.M., Laureys, S., Ling, G.S.F., Nakase-

Richardson, R., Seel, R.T., Yablon, S., Getchius, T.S.D., Gronseth, G.S., Armstrong, M.J. (2018) Practice guideline update recommendations summary:

Disorders of consciousness. Neurology, 91, 1-11. doi: 10.1212/WNL.0000000000005926

7. Giacino, J.T., Schnakers, C., Rodriguez-Moreno, D., Kalmar, K., Schiff, N., Hirsch, J. (2009). Behavioral assessment in patients with disorders of

consciousness: Gold standard or fool’s gold?. Progress in Brain Research, 177, 63-72. https://doi.org/10.1016/S0079-6123(09)17704-X

8. Klingshirn, H., Grill, E., Bender, A, Strobl, R., Mittrach, R., Braitmayer, K., Muller, M., (2015). Quality of evidence of rehabilitation interventions in longterm

care for people with severe disorders of consciousness after brain injury: A systematic review. J Rehabil Med, 47, 577-585.

9.Kothari, S., Gilbert-Baffoe, E., & O’Brien, K.A. (2018). Disorders of Consciousness. In Eapen & Cifu (Eds.), Rehabilitation After Traumatic Brain Injury (pp.

191-214).

10. Laureys, S., Boly, M., Moonen, G., and Maquet, P. (2009). Coma. Encyclopedia of neuroscience, 2, 1133-1143.


https://doi.org/10.1016/S0079-6123(09)17704-X

References cont.

11. Ontario Neurotrauma Foundation. (2016, October). Clinical practice guideline for the rehabilitation of adults with moderate to severe tbi: Section I:



12. Ontario Neurotrauma Foundation. (2016, October). Clinical practice guideline for the rehabilitation of adults with moderate to severe tbi: Section II :



13. Riganello, F., Arcuri, F., Pugliese, M.E., Lucca, L.F., Dolce, G., & Sannita, W.G., (2015). Coma recovery scale-r: Variability in the disorder of

consciousness. BMC Neurology, 15:186, 1-7. doi https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4599033/pdf/12883_2015_Article_455.pdf

14. Rosella, C., Placido, B.,Savatore Calabro, R., (2013). Pharmacotherapy for disorders of consciousness: Are ‘awakening’ drugs really a possibility?. Drugs,

73(17), 1849–1862.

15. Schnakers, C., Vanhaudenhuyse, A., Giancino, J., Ventura, M., Boly, M., Majerus, S., Moonen, G., Laureys, S. (2009). Diagnostic accuracy of the

vegetative and minimally conscious state: Clinical consensus versus standardized neurobehavioral assessment. BMC Neurology, 9(35), 1-5.

https://bmcneurol.biomedcentral.com/track/pdf/10.1186/1471-2377-9-35.

16. Seel, R.T., Douglas, J., Dennison, A.C., Heaner, S., Farris, K., Rogers, C. (2013). Specialized early treatment for persons with disorders of consciousness:

Program components and outcomes. Arch Phys Med Rehabil, 94(10,) 1908-23.

17. Whyte, J., & Dipasquale, M. C. (1995). Assessment of vision and visual attention in minimally responsive brain injured patients. Archives of physical

medicine and rehabilitation, 76(9), 804-810.

18. Whyte, J., DiPasquale, M. C., & Vaccaro, M. (1999). Assessment of command-following in minimally conscious brain injured patients. Archives of Physical

Medicine and Rehabilitation, 80(6), 653-660.

19. Wilson, B.A., Dhamapurkar, S., & Rose, A. (2016). Assessment and treatment of people with a disorder of consciousness: An account of some recent

studies. Psychology & Neuroscience, 9(2), 221–229.



https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4599033/pdf/12883_2015_Article_455.pdf

https://bmcneurol.biomedcentral.com/track/pdf/10.1186/1471-2377-9-35

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