TV dramas depict people in comas who one day suddenly awaken to full consciousness. In real life, recovery is gradual, requiring specialized care as people move through disorders of consciousness. When a person has a severe accident, stroke, heart attack, or drug overdose, the traumatic impact or lack of oxygen can cause brain damage that may result in a coma. Characterized by closed eyes and a complete lack of conscious interaction, the coma is the lowest stage of disordered consciousness.
Some individuals regain full consciousness relatively quickly after a coma, while others can transition to another stage of disorder of consciousness, such as the vegetative state where the patient opens their eyes but remains unresponsive. The vegetative state is sometimes referred to as the unresponsive wakefulness syndrome. In this stage, patients don't meaningfully respond to the outside world and nothing exists above a reflex. The third stage of disordered consciousness is the minimally conscious state, where patients occasionally but inconsistently do meaningful behaviors.
Depending on the injury severity and what parts of the brain are damaged, patients can progress through all disorders of consciousness stages or move from a coma directly to a minimally conscious state. People can make substantial improvements from any of these stages over time, especially with specialized care. MossRehab is one of a small number of rehabilitation hospitals throughout the country with a specialized inpatient rehabilitation program focused on coma evaluation and recovery .
MossRehab Responsiveness Program
MossRehab Disorders of Consciousness (DOC) Responsiveness Program provides rehabilitative services to patients determined to have a disorder of consciousness after emerging from a coma. Conducted at the Drucker Brain Injury Center at MossRehab Elkins Park, the subspecialty inpatient program brings together a multi-disciplinary team of clinicians experienced in DOCs in one location to provide care to patients in unresponsive wakefulness or a minimally conscious state.
“The Responsiveness Program is usually the first stop after acute care,” explains John Whyte, MD, PhD, Founding Director and Institute Scientist Emeritus at MossRehab Rehabilitation Research Institute (MRRI) and the DOC Responsiveness Program. “We have experienced teams of clinicians including rehabilitation doctors, therapists, nurses, neuropsychologists, and social workers who work together in providing patient care. It is one of about 10 programs around the country dedicated to persons with disorders of consciousness.”
The Program has several areas of focus. First, clinicians identify and stabilize a patient's medical problems to remove any barriers preventing recovery or that may obscure their ability to interact with the outside world. This patient population often has difficulty maintaining stable vital signs and may have medical complications like seizures or bleeding which could jeopardize recovery. Optimizing medical conditions helps improve the chance of recovering consciousness.
“We don’t want to make a mistake in diagnosing a person in a particular disorder of consciousness stage when it might be contributable to another medical state,” notes Whyte. “For example, if a person has paralysis in their arm, they might be unable to move their arm in response to a command.”
Next, the patient’s state of consciousness is accurately characterized. “We track eye openings and utilize a neurobehavioral assessment scale called The Coma Recovery Scale to determine a person’s level of consciousness,” says Michael Marino, MD, Director of the DOC Responsiveness Program. “We also develop specific protocols to evaluate a patient to determine whether or not an individual is responding with a reflex or providing a real response to a command or stimulus.”
For example, clinicians may present a patient with a family photo and move it back and forth to monitor for any eye movement. Using data collected from multiple clinicians on the same protocol, the team can establish the patient's state of consciousness and track progress.
Plans of Treatment
After assessing the level of consciousness, the team devises the rehabilitation course and treatment plan using their collective clinical experience. Every patient receives three hours of therapy a day provided by physical, occupational, and speech therapists; care from nurses trained in rehabilitation, and is visited every day by a physician.
"Since many patients have difficulty talking, we use a simple communication system such as a thumbs up or thumbs down to indicate 'yes' or 'no,' or an eye gaze system where the patient moves their eyes towards the desired answer," notes Dr. Marino. "It may sound crude but it's effective, and sometimes it is the first time since their injury, these patients can express if they are in pain, tired, happy, etc."
Medications may also help accelerate the recovery of consciousness by making patients more awake to improve their chance of responding to the outside world. Newer treatments on the horizon include transcranial magnetic stimulation (TMS) and transcranial direct current stimulation, which apply small electrical stimulus over the brain surface to improve awareness. "Imaging technology including PET scanning (detects abnormal metabolism of the organs or tissues), high-density electroencephalograms (records electrical signals of the brain), and functional MRIs (shows metabolic activity of the brain tissue) also are under study as methods to determine someone's level of consciousness and help predict their response to treatment," says Dr. Marino.
Patient progress is continuously measured to determine the rate of improvement or decline. Social workers along with a neuropsychologist and physician discuss progress and prognosis with families, as well as future care options. Families also receive education on patient care and how to look for changes in physical and cognitive abilities so former patients showing improvement can potentially return to MossRehab for re-evaluation and additional treatment.
Value of Specialized Care
"The goal is to help patients manage medical problems, make physical and cognitive improvements to emerge from disorders from consciousness and eventually transition into traditional inpatient brain injury rehabilitation," says Dr. Marino. "Studies on this patient population show people continual make improvements over the course of years, with one study showing more than two-thirds of patients achieving independence in mobility over the course of 10 years."
Marino notes that the American Congress of Rehabilitation Medicine and the American Association of Neurology endorse that people with disorders of consciousness should be treated in centers that specialize in the condition. The level of experience and knowledge offered by programs such as MossRehab's DOC Responsive Program results in better outcomes for patients.
“Research conducted by my colleagues and others in the United States and Europe show that about 20% of patients who are admitted to rehab in a state of unconsciousness go on to independent living,” notes Dr. Whyte.
Serving as an advocate for people with disorders of consciousness, Dr. Whyte is working to improve access to skilled rehabilitation, such as that offered by MossRehab's Responsive Program. "I advocate for people with disorders of consciousness to have access to high-quality expert evaluation, management and care," says Whyte. "As this population can make progress when their needs are met, I'm extremely motivated to get people access to skilled rehabilitation."
Other initiatives led by Dr. Whyte include extending the amount of time to care for patients who are in very complex vegetative states, testing and developing medicines specifically for individuals with disorders of consciousness, and authoring recommendations for minimum competencies needed by rehabilitation programs serving this population.
Read more about Dr. Whyte’s work with the MossRehab Disorders of Consciousness Rehabilitation Program.