D i s o rd e r s o f C o n s c i o u s n e s s

Blessen C. Eapen, MDa,*, Jason Georgekutty, DOb,

Bruno Subbarao, DOa, Sheital Bavishi, DOc, David X. Cifu, MD
d

KEYWORDS
 Disorder of consciousness  Rehabilitation  Coma  Vegetative state
 Minimally conscious state  Traumatic brain injury

KEY POINTS
 Disorders of consciousness (DOC) are altered states of pathologic consciousness, which
can be subdivided into coma, vegetative state, and minimally conscious state (MCS)
based on neurobehavioral function.
 The Coma Recovery Scale-Revised assessment scale is recommended in DOC for clinical
practice and research.
 Emergence from MCS is defined as reliable and consistent functional object use and func-
tional communication.
 In a randomized, double-blinded, placebo controlled study, Amantadine improved func-
tional recovery in patients with DOC.

INTRODUCTION

Annually, approximately 2.5 million people sustain a traumatic brain injury (TBI) in the
United States, and more than 5.3 million people live with a TBI-related disability. TBI
not only impacts the life of an individual and their family but also has a large societal
and economic toll. The estimated economic cost of TBI in 2010, including direct and
indirect medical costs, was approximately $76.5 billion. In addition, the cost of fatal
TBIs and TBIs requiring hospitalization accounts for approximately 90% of the total
TBI medical costs.1 Approximately 0.3% severe TBIs can result in Disorders of Con-
sciousness (DOC).2 DOC is a state of prolonged altered consciousness, which can be

Disclosure Statement: The views, opinions, and/or findings expressed herein are those of the
authors and do not necessarily reflect the views or the official policy of the Department of Vet-
erans Affairs or US Government.
a
Polytrauma Rehabilitation Center, South Texas Veterans Healthcare System, 7400 Merton
Minter, San Antonio, TX 78229, USA; b Kessler Institute for Rehabilitation, 201 Pleasant Hill
Road, Chester, NJ 07830, USA; c Traumatic Brain Injury Rehabilitation Program, Department
of Physical Medicine and Rehabilitation, Ohio State University Wexner Medical Center, 480
Medical Center Drive, Columbus, OH 43210, USA; d Department of PM&R, Virginia Common-
wealth University, US Department of Veterans Affairs, VA/DoD Chronic Effects of NeuroTrauma
Consortium, 1223 E. Marshall Street, P.O. Box 980677, Richmond, Virginia 23284-0667, USA
* Corresponding author.
E-mail address: [email protected]

Phys Med Rehabil Clin N Am 28 (2017) 245–258

http://dx.doi.org/10.1016/j.pmr.2016.12.003 pmr.theclinics.com
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246 Eapen et al

categorized into coma, vegetative state (VS), and minimally conscious state (MCS).
DOC can prove difficult to diagnose and treat and can result in increased burden of
care for families and facilities. In this article, the authors review the definition, diag-
nosis, imaging, and treatment interventions for this difficult patient population.

CONSCIOUSNESS

Historically, the concept of human consciousness has been difficult to describe on

both a philosophic and a scientific level. Previous models often describe this phenom-
enon as a subjective experience, which consequently poses a diagnostic challenge in
patients with a DOC. However, recent advances in modern medicine have allowed for
improved survivability of acute brain injury and have secondarily imparted insight into
the neural correlates of consciousness. Clinically, the 2 components that separate
consciousness from unconsciousness are arousal and awareness.3 Wakefulness is
a state of arousal, which can be assessed by the presence of eye-opening and brain-
stem responses. The depth of wakefulness can be evaluated objectively using mea-
sures such as the Glasgow Coma Scale.4 On a neuroanatomic level, arousal is
mediated by the ascending reticular activating system of the upper brainstem. Activa-
tion of the cerebral cortex occurs with passage of sensory information from the upper
brainstem via reticulothalamocortical and extrathalamic pathways. From a neurobio-
logic perspective, the conscious awake state is associated with a high energy demand
and electrical activity within the corticothalamic system. This is further supported by
electroencephalogram recordings (EEG), which show that increasing levels of arousal
are associated with increased frequency of electrical activity in the cerebral cortex.4
Conversely, a decline in arousal is associated with reduction in excitatory neuromodu-
latory influences. The global deafferentation and disruption of the corticothalamic net-
works could explain the dysfunction in arousal seen in severe brain injuries.5
Awareness refers to the ability of an individual to respond to both external and internal
stimuli in an integrated manner. It is inferred by command following and neurobehavio-
ral assessment.6 On a neuroanatomic level, the connectivity of frontoparietal regions
and the thalamus appears to play a role in the maintenance of consciousness.7 This is
supported by functional MRI (fMRI) studies, which suggest dysfunctional cerebral
connectivity in widespread areas of the frontoparietal networks in patients with
DOC.8 In a healthy individual, an increase in arousal is associated with an increase
in awareness in a linear fashion along the continuum of conscious states.9 A dissoci-
ation of these 2 components of consciousness is seen in pathologic states, such as in
the VS and MCS.

CLINICAL ENTITIES
Brain Death
In 1995, the American Academy of Neurology (AAN) provided practice guidelines for
the determination of brain death. They emphasized 3 clinical findings that indicate
cessation of brain function: (1) coma (of known cause), (2) absence of brainstem re-
flexes, and (3) apnea. Before this determination, other causes for brainstem dysfunc-
tion should be excluded, including shock/hypotension, hypothermia, central nervous
system depressants, spinal cord injury, and electrolyte and/or endocrine abnormal-
ities. There is no consensus regarding the timing of follow-up testing, but clinicians
must use judgment and perform serial evaluations to exclude the possibility for recov-
ery. A diagnosis of brain death is ominous, and there have been no reports of neuro-
logic recovery once determined by the 1995 AAN practice parameters.10,11

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 Disorders of Consciousness 247

Coma
A coma is a state of unconsciousness characterized by a lack of arousal and aware-
ness. The defining clinical feature is the complete loss of spontaneous or stimulus-
induced arousal.5 There is no eye opening, and EEG testing reveals the absence of
sleep-wake cycles. Structural lesions usually involve diffuse cortical or white matter
damage, or a brainstem lesion.6 Those who survive this stage will begin to awaken
and transition to a VS/unresponsive wakefulness state (UWS) or MCS within 2 to
4 weeks.5,12

Vegetative State/Unresponsive Wakefulness State

The VS is thought of as an unconscious, dissociative state of wakefulness without
awareness. The patient’s eyes open spontaneously, and EEG testing reveals the pres-
ence of sleep-wake cycles. Patients may arouse by provocation or external stimuli, but
they show no signs of conscious perception or deliberate action.4 Interestingly, these
patients may perform stereotyped gestural movements such as yawning, chewing,
crying, smiling, or moaning, but these are unrelated to context.6 The presence of
wakefulness suggests preserved brainstem functioning, but the lack of awareness
suggests an underlying cortical dysfunction. Likewise, functional neuroimaging has
shown sensory stimuli will activate primary cortical areas, but not the higher order
cortical areas thought necessary for awareness.4 With proper medical care, a patient
in a VS can survive for many years.

Minimally Conscious State

The MCS is characterized by a severe impairment of consciousness, with evidence of
wakefulness and partial preservation of awareness. Unlike the VS, there are discern-
ible, purposeful behaviors that can be differentiated from reflexive behavior. Originally,
these patients were categorized as VS, but there was evidence that they compara-
tively had meaningful improvement in outcomes. Therefore, in 2002 the Aspen Neuro-
behavioral Conference Workgroup established guidelines for MCS. The hallmark of
MCS is inconsistent but reproducible, command following. The preservation of corti-
cothalamic connections might explain why patients in MCS retain the capacity for
cognitive processing. The patient may exhibit visual pursuit, emotional responses,
and gestures to appropriate environmental stimuli, but are unable to functionally
communicate their thoughts or feelings. Recently, a further subcategorization of the
MCS was proposed by Bruno and colleagues,13 based on the complexity of observed
behavioral responses, to minimally conscious plus (MCS1) and minimally conscious
minus (MCS ).

Acute Confusional State

Once emerged from the MCS, patients continue to experience a transient period of
disorientation and agitation. The full array of symptoms associated with the acute
confusional state can also include irritability, distractibility, anterograde amnesia, rest-
lessness, emotional lability, impaired perception, attentional abnormalities, and a dis-
rupted sleep-wake cycle.14 A key pattern to this state is the day-to-day fluctuation of
behavioral responses. The return of behavioral consistency despite situational
stresses may indicate a resolution of this period.

Locked in Syndrome
Locked in syndrome is a rare condition characterized by intact consciousness and
cognition, but with anarthria and quadriplegia.15 It is likely caused by damage to the

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248 Eapen et al

ventral pons and the corticospinal/corticobulbar pathways, which communicate with

the brainstem.5 Patients have intact sensation, and eye movements are spared, allow-
ing for gaze-based communication. Over time, some patients may recover some con-
trol of the fingers, toes, or head. This atypical presentation, with lost speech and motor
control, places these patients at risk for misdiagnosis as a DOC.

CLINICAL EXAMINATION AND QUANTITATIVE ASSESSMENT

A focused clinical examination is essential in distinguishing between DOC. Specif-

ically, 7 domains should be tested and include sleep-wake cycles, awareness, motor
skills, auditory function, visual function, communication, and emotional integrity
(Table 1).16 Sleep-wake cycles alone, detected through observation of intermittent
eye-opening, will help differentiate someone in a VS from someone in a coma. The
presence of awareness will further distinguish someone in a MCS from those in a
vegetative one.
When testing the remainder of the domains, it is worth noting that certain caveats
exist. First, yes/no responses can be given through direct verbal communication or
through gestures such as a thumbs-up. These responses can be incorrect in regards
to the questions asked, but they must be reproducible. Second, behavioral responses
should demonstrate a definite relationship with their stimuli, such that reflexive activity
cannot explain the response. For example, visual tracking of objects or persons,
appropriate emotional responses to nonneutral content, and reaching for or grasping
and manipulating objects. It is important to test a wide array of behavioral responses
within the abilities of the patient and perform serial examinations to ensure accuracy.
Last, it is imperative that a complete physical examination be done to provide insight
for any findings that may obscure appropriate diagnosis, including but not limited to
effects of sedative medications, aphasia, apraxia, motor impairments, or sensory
deficits.16
As the patient continues along the spectrum of recovery, emergence from an MCS
would be evidenced by 2 distinct behaviors. The first is functional interactive commu-
nication, which would have to be demonstrated through means of correct yes/no re-
sponses to 6 situational questions on 2 consecutive examinations. Examples of such
questions could include, “Are you lying in bed right now?” or “Am I holding a pen in my
hand?” Again, responses can be gestural, written, or verbal. The second behavior is
the functional use of 2 different objects that can be validated. Examples include the
patient bringing a toothbrush to their mouth or pointing a remote to a television.16

BEHAVIORAL ASSESSMENT SCALES

Diagnosis of DOC is based on clinical observations and standardized neurobehavioral

assessments. Neurobehavioral assessment scales require standardized scoring and
ability to detect subtle signs of consciousness.5 Several scales have been developed
to assess DOC patients. In 2010, a special task force, with the American Congress of
Rehabilitation Medicine Special Interest Group in Disorders of Consciousness,
reviewed 13 scales, of which 6 proved to be sensitive for detecting conscious aware-
ness.17 Of those 6 scales, the Coma Recovery Scale-Revised (CRS-R) had the stron-
gest content validity based on the Aspen criteria.5
Coma Recovery Scale-Revised
The Coma Recovery Scale (CRS) was first described in 1991 and revised in 2004
(CRS-R).18 It has had multiple studies that have proved its sensitivity and reliability
in diagnosis and monitoring progress in DOC patients. The CRS-R is a 23-item scale

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Table 1
Comparing features of coma, vegetative state, and minimally conscious state

Sleep-Wake Cycles Awareness Motor Auditory Visual Communication Emotional

Coma Absent Absent Reflexive None None None None
VS Present Absent Purposeless/postures/ Startle Startle None Reflexive
withdraws to noxious
stimuli
MCS Present Partial Purposeful/localizes Localizes sound Sustained fixation Intelligible verbal Contingent responses
noxious stimuli or pursuit or gestural

Adapted from Giacino JT, Ashwal S, Childs N, et al. The minimally conscious state: definition and diagnostic criteria. Neurology 2002;58(3):349–53.

Disorders of Consciousness
249
250 Eapen et al

comprising 6 subscales, whose items are arranged hierarchically from reflexive to

cognitively mediated processes. Subscales address visual, auditory, motor, oromotor,
communication, and arousal categories. Emergence criteria are assessed by the
communication (yes/no accuracy) and motor subscales (functional object use).18,19
Currently, this is the recommended scale because of its sensitivity and validity. Prac-
titioner experience increases the interrater reliability and test-retest reliability. Training
can be done by establishing interdisciplinary and particularly trained teams, using
instructional videos, multicenter residency agreements, workshops, and video
conferences.20

Sensory Modality and Rehabilitation Techniques

Sensory modality and rehabilitation techniques or SMART was developed by Occupa-
tional Therapists at the Royal Hospital for Neuro-disability in London, United Kingdom
as both an assessment and a treatment tool for patients in VS or MCS.21 SMART com-
prises 2 components. The formal component, conducted by the SMART assessors,
includes the SMART Sensory Assessment and the SMART Behavioral Observation
Assessment. The informal component consists of information from family and care-
givers regarding observed behaviors and premorbid interests, likes, and dislikes.21
The SMART requires a 5-day training course to become an assessor and prior submis-
sion of a portfolio to gain access to the assessment tool.

Western Neurosensory Stimulation Profile

Western neurosensory stimulation profile (WNSSP) consists of 32 items, which assess
patients’ arousal/attention, expressive communication, and response to auditory, vi-
sual, tactile, and olfactory stimulation. The WNSSP takes 20 to 40 minutes to admin-
ister and has shown internal consistency and standardized scoring and
administration. It does rely on visual comprehension and tracking.22

Wessex Head Injury Matrix

Wessex Head Injury Matrix (WHIM) is a 62-item scale, ordered in hierarchy, that as-
sesses communication ability, cognitive skills, and social interaction. Assessment is
by observation and testing tasks used in everyday life. The WHIM was created to
follow a patient from emergence from coma to emergence from posttraumatic
amnesia. It could take anywhere from 30 to 120 minutes to administer. To obtain
the rating scale and training manual, there is a fee and training is required because
it has been noted that interrater reliability and test-retest reliability relies on
experience.23

Sensory Stimulation Assessment Measure

Sensory stimulation assessment measure consists of presentation of standardized
stimuli, including visual, auditory, tactile, olfactory, and gustatory. It is based on Glas-
gow Coma Scale responses of eye opening, motor, and vocalization. It is meant to
follow a DOC patient long term and to be used with physical and neurological exam-
inations. It takes 40 to 50 minutes to administer. It is useful in guiding treatment
because the rater can evaluate what stimuli gives the most responses.24

Coma Near Coma Scale

Coma Near Coma Scale consists of an 11-item test with specific and structured sen-
sory stimulation for auditory, visual, olfactory, and tactile modalities. Vocalization and
command response are also tested. It takes 15 minutes to administer and has good

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 Disorders of Consciousness 251

interrater reliability with self-training by reviewing instructions on the back of the form.
It is good for evaluation but not guiding treatment.22,25

Disorders of Consciousness Scale

Disorders of Consciousness Scale (DOCS) consists of 23 items with 8 subscales:
auditory, visual, tactile, olfactory, proprioceptive/vestibular, taste/swallowing. It takes
about 45 minutes to administer and has standardized administration. It is a free test
and requires training with a 2-hour DVD and observation by a trained practitioner. It
covers testing of only 3 of the 4 MCS diagnostic criteria.17 The DOCS measure is
not used by practicing clinicians.

IMAGING AND COMPLEMENTARY STUDIES

Misdiagnosis in DOC is as high as 40%, which creates an obvious need for objective
measures through neuroimaging.26 Although debate persists as to the utility of struc-
tural neuroimaging by means of computed tomography and MRI apart from initial eval-
uation or in the event of an acute neurologic deterioration, serial neuroimaging may be
helpful in monitoring the evolution of cerebral hematomas or monitoring for brain atro-
phy.27 Advanced neuroimaging, on the other hand, has shown promise through
several studies that elucidated differences in comparing patients in a VS to those in
a MCS.

PET Scan
Laureys and colleagues12 demonstrated that an auditory stimulus activated second-
ary brain regions thought to be associated with awareness in minimally conscious pa-
tients, but which remained inactive in patients considered to be in a VS using PET
scans. Similarly, in 2008, Boly and colleagues28 used PET scanning to observe activa-
tion of the pain centers in the cortex and thalamus in minimally conscious, VS, and
control groups. The study concluded that levels of neuronal activity were significantly
lower in the VS group as compared with the MCS and control groups, which were
essentially equivalent. Still, in 2010, Fisher and Appelbaum29 argued that brain activity
without visible corresponding behavior cannot be assumed to mean that a specific
cognitive task is indeed being, or attempting to be, performed.

Functional MRI
fMRI is another modality that can play a complementary diagnostic role for patients
with DOC that do not have metallic implants. This modality has the additional benefit
of not exposing patients to radiation. In 2010, Monti and colleagues26 used fMRI to
study the volitional ability to create mental imagery in patients with DOC. Of 23 pa-
tients diagnosed to be in a VS, 4 were able to perform volitional imagery tasks, putting
their clinical diagnoses into question. Other similar studies using fMRI with differing
paradigms for testing demonstrated promising results, although most contained a
small research subject pool. More research into this area is certainly warranted for
diagnostic and, perhaps, communicative purposes.

Electroencephalograms
EEGs are a cheaper alternative to the fMRI, and they still retain diagnostic utility.30 One
proposed mechanism to identify changes in consciousness may be through recogni-
tion of normal sleep-wake cycles. A 2011 study by Landsness and colleagues31
demonstrated the presence of sleep-wake cycles similar to a healthy population in
MCS patients. This was in contrast to patients in a VS, that, although had observable

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252 Eapen et al

behavioral periods of eye-opening and eye-closing, their EEGs failed to show any
resemblance to normal sleep patterns.

Event-Related Potentials
Event-related potentials (ERP) can help to understand subtle responses linked to con-
sciousness. As the name suggests, these potentials are specifically related to a stim-
ulus, whether it be motor, sensory, or cognitive. An EEG, once averaged, will cancel
out whole brain waveforms, revealing only the ERPs. ERPs can be subdivided into
short-latency, where the potentials are occurring before 100 ms, and long-latency
cognitive ERPs, which occur after 100 ms. In this way, one can understand where
the potentials are being derived from, because potentials occurring before 100 ms
most likely are from the ascending pathways and primary cortex, and those occurring
after from the cortical and subcortical structures. Thus, cognitive ERPs are considered
more directly related to cognitive processing, arousal, and awareness. They have
been found to be useful in eliciting remaining cognitive functions, especially when us-
ing emotionally linked stimuli. Short-latency ERPs, on the other hand, show promise
as a predictor of negative outcomes in patients with DOC and tout a low false-
negative rate.32

Bispectral Index/Power Spectral Analysis

Two EEG derivatives known as bispectral index (BIS) and power spectral analysis
have also been researched for utility as diagnostic tools. BIS was developed for anes-
thesiologists to measure the depth of sedation of their patients. In 2008, Schnakers
and colleagues33 proposed BIS as a way to distinguish the MCS from the VS by
observing in their study that (1) BIS levels were demonstrably lower in VS than in
MCS and (2) a strong correlation exists between BIS levels and CRS-R, especially
compared with other EEG parameters. In a similar manner, power spectral analysis,
a method used when there is a significant delay in the neural response after a stimulus,
was studied in this same patient population. Goldfine and colleagues34 observed 2 pa-
tients in an MCS and recorded any EEG evidence of awareness by means of asking
the patients to imagine different scenarios. Although this study was small, they posit
power spectral analysis as a potential for diagnostic and communicative purposes
for patients with DOC.

TREATMENT INTERVENTIONS

The primary goal of DOC rehabilitation programs is to promote arousal while prevent-
ing secondary medical complications. Although there are no consensus treatment
guidelines for DOC patients, there are several pharmacologic and nonpharmacologic
treatments available.

Pharmacologic Treatment
Amantadine
Dopamine agonist and N-methyl-D-aspartate antagonist have been used in DOC for
hypoarousal. In a large, multicenter, double-blind, placebo-controlled trial, the ability
of Amantadine versus placebo to accelerate functional recovery among patients with
nonpenetrating TBI in a vegetative or MCS was studied. A total of 184 patients were
treated for 1 month, in the period between 4 and 16 weeks after severe TBI while
they also received inpatient rehabilitation (IPR). The rate of functional recovery was
measured by the Disability Rating Score (DRS), and there was a statistically significant
rate of weekly improvement of 0.24 (P 5 .007) compared with the placebo group.

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 Disorders of Consciousness 253

Patients started with Amantadine 100 mg twice daily and underwent serial escalations
in daily dosage up to 400 mg depending on evidence of a positive response on DRS
score. Interestingly, regardless of the interval since injury, the benefit of Amantadine
appeared consistent.35 Furthermore, although the rate of recovery diminished after
a washout period, gains were sustained after cessation of the drug.
Bromocriptine
Direct agonist at the D2 receptor has limited information regarding its use in patients
with DOC. A 5-patient case review series involving patients in a VS who were admin-
istered Bromocriptine 1 month after TBI exhibited encouraging results. When
compared with a literature-based control group at 3, 6, and 12 months, there was
an improvement in the DRS and CRS scores.36 Unfortunately, this study had a low
sample size and a lack of experimental control, which limited the significance of the
findings.

Modafinil
The exact mechanism of action of Modafinil is unknown, but it is thought to stimulate
adrenergic, histaminergic, glutaminergic activity and cause decreased gamma amino-
buytric acid (GABA) activity in the brain. In a single-center, double-blind, placebo-
controlled trial by Jha and colleagues37 to evaluate Modafinil in the treatment of
excessive daytime sleepiness in patients with chronic TBI, there was no clear evi-
dence between treatment with Modafinil versus placebo. No clear evidence for its
use in DOC currently exists, and more research is warranted.
Methylphenidate
Methylphenidate is a neurostimulant that acts synaptically by blocking the reuptake of
Dopamine and Norepinephrine. In a retrospective cohort study, 8 patients who were in
a post–cardiac arrest comatose state and received Methylphenidate exhibited an
improvement in following commands and a higher survival rate to hospital discharge
(62.5% vs 27.7%; P 5 .005) than those who did not.38 The findings from a recent PET
study suggest that Methylphenidate may help to normalize cerebral glucose meta-
bolism and neural circuits after brain injury.39

Zolpidem
Zolpidem is a sedative-hypnotic and a GABA agonist. There have been several case
studies in the literature describing a transient, paradoxic, awakening effect after
administration of zolpidem.40 A large, prospective, placebo-controlled, double-blind,
single-dose, crossover study was designed to study the effects of Zolpidem on recov-
ery of consciousness in vegetative and minimally conscious patients. Of the 84 total
participants, only 4 definite “responders” (5% of total) were identified, which had no
demographic or clinic predictors of response. Further studies are warranted to identify
why and how Zolpidem is active in such a selective manner.41
Levodopa
Levodopa is a precursor of the neurotransmitters dopamine, norepinephrine, and
adrenaline. An 8-patient, prospective study of patients in a VS, who were administered
Levodopa approximately 104 days after their TBI, was performed. All of the patients
made improvement in their consciousness, and 7 of 8 patients had full recovery of
consciousness. Interestingly, gradual increases of Levodopa doses were associated
with increasing complexity of motor responses.42 In a study by Matsuda and col-
leagues,43 patients in a VS or MCS, with symptoms of Parkinsonism and neuroradio-
logic evidence of damaged dopaminergic pathways, were responsive to Levodopa.
Although promising, both studies are limited by their small sample size.

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254 Eapen et al

Nonpharmacologic Treatments
Nonpharmacologic treatments for DOC can vary from rehabilitation with specially
trained therapists to noninvasive and invasive brain stimulation. More data are
emerging on the benefit of early rehabilitation and interventions for this group of pa-
tients. Specialized neurorehabilitation programs in an IPR facility setting have shown
improved emergence to consciousness. Noninvasive brain stimulation and neuroreha-
bilitation when used in conjunction are synergistic and can enhance neuroplasticity
more than either alone.44,45

Neurorehabilitation
Specialized rehabilitation protocols for DOC population are essential for improving re-
covery and long-term care. In 2013, National Institute on Disability and Rehabilitation
Research and Traumatic Brain Injury Model Systems evaluated the functional out-
comes at 5 years from patients admitted to IPR and unable to follow commands. Their
study showed substantial proportions of the patients not following commands on
admission to IPR recovered independent functioning over 5 years (56%–85% of pa-
tients in the early recovery group and 19%–36% of patients in the late recovery group),
particularly if they followed commands before discharge (early recovery group).46
Specialized multidisciplinary rehabilitation with acute medical management and
90 minutes or more of therapy are likely to show improved consciousness and body
function. Medical management can focus on prevention and/or treatment of medical
complications of TBI, including paroxysmal sympathetic hyperactivity, spasticity,
respiratory insufficiency, prevention and treatment of infections, deep venous throm-
bosis, and wounds (pressure ulcers). Neurorehabilitation should use standardized
assessments for measurement of DOC level performed by trained clinicians and the
interdisciplinary team to focus on recovery of consciousness, functional communica-
tion, and positioning and mobility.47,48 The team consists of physicians, rehabilitation
nursing, physical therapy, occupational therapy, speech language pathology, rehabil-
itation psychology, neuropsychology, case management, and social work. It has been
seen that with specialized early treatment, including acute medical care and rehabil-
itation, that patients may be able to transition to mainstream rehabilitation and emerge
to consciousness.47 Each member of the team is essential in the success of a DOC
rehabilitation program. Families who receive comprehensive education and hands-
on training with ongoing follow-up and support may be able to take care of patients
with DOC at home versus facility placement.47

Transcranial direct current stimulation

Transcranial direct current stimulation (TDCS) is a form of neurostimulation that de-
livers a low constant current to an area of the brain using scalp electrodes. Anodal
TDCS elicits prolonged increases in cortical excitability and facilitates underlying
regional activity. Cathodal TDCS has the opposite effect.49 Emerging data exist on
the use of TDCS for transient improvement in consciousness in patients in MCS but
not UWS.50,51 TDCS when used in conjunction with rehabilitation may enhance
cortical plasticity and recovery in patients with DOC. Therefore, the ease of use, min-
imal risk of harm, and portability may provide an additional intervention for this
population.49

Transcranial magnetic stimulation

Transcranial magnetic stimulation (TMS) provides neuromodulation with the applica-
tion of rapidly changing magnetic fields to the scalp via a copper wire coil connected
to a magnetic stimulator. Repetitive trains of TMS can suppress or facilitate cortical

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 Disorders of Consciousness 255

processes depending on stimulation parameters. Effect of TMS has been seen to have
modulatory effects longer than the duration of the stimulation, thereby modulating
neural plasticity. Case reports have been published that improved neural conduction
mediates neurobehavioral gains in coma recovery.52
Deep brain stimulation
Deep brain stimulation is an invasive brain stimulation that requires surgical implanta-
tion of a deep brain stimulator. Thalamic and brainstem control of forebrain arousal is
not a novel concept. This neurophysiologic concept has led to the consideration of
thalamic electrical stimulation to promote consciousness in DOC patients.53

SUMMARY

DOC presents both a scientific and a clinical challenge for clinicians caring for indi-
viduals with DOC. Currently, behavioral assessment remains the gold standard for
diagnosis of these individuals, but advanced neuroimaging and electrophysiological
techniques present possibilities for improvement of the current diagnostic classifica-
tion systems. Future studies need to focus on diagnostic as well as therapeutic inter-
ventions to aid in the recovery from DOC.

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