Specialized early treatment for persons with disorders of consciousness: program components and outcomes

Abstract

Objectives: To describe a specialized early treatment program for persons with disorders of consciousness (DOC) that includes family education; to identify rates of secondary conditions, imaging used, and selected interventions; and to evaluate outcomes.

Design: A single-center, retrospective, pre-post design using electronic medical record data.

Setting: A Commission on Accreditation of Rehabilitation Facilities-accredited, long-term acute care hospital that provides acute medical and inpatient rehabilitation levels of care for people with catastrophic injuries.

Participants: Persons (N=210) aged 14 to 69 years with DOC of primarily traumatic etiology admitted at a mean ± SD of 41.0 ± 27.2 days postinjury; 2% were in coma, 41% were in the vegetative state, and 57% were in the minimally conscious state.

Interventions: An acute medical level of care with ≥90 minutes of daily interdisciplinary rehabilitation and didactic and hands-on caretaking education for families.

Main outcome measures: Coma Recovery Scale-Revised, Modified Ashworth Scale, and discharge disposition.

Results: Program admission medical acuity included dysautonomia (15%), airway modifications (79%), infections (eg, pneumonia, 16%; urinary tract infection, 14%; blood, 11%), deep vein thrombosis (17%), pressure ulcers (14%), and marked hypertonia (30% in each limb). There were 168 program interruptions (ie, 139 surgeries, 29 nonsurgical intensive care unit transfers). Mean length of stay ± SD was 39.1 ± 29.4 days (range, 6-204d). Patients showed improved consciousness and respiratory function and reduced presence or severity of pressure ulcers and upper extremity hypertonia. At discharge, 54% showed sufficient emergence from a minimally conscious state to transition to mainstream inpatient rehabilitation, and 29% did not emerge but were discharged home to family with ongoing programmatic support; only 13% did not emerge and were institutionalized.

Conclusions: Persons with DOC resulting primarily from a traumatic etiology who receive specialized early treatment that includes acute medical care and ≥90 minutes of daily rehabilitation are likely to show improved consciousness and body function; more than half may transition to mainstream inpatient rehabilitation. Families who receive comprehensive education and hands-on training with ongoing follow-up support may be twice as likely to provide care for medically stable persons with DOC in their homes versus nursing facility placement.

Keywords: ACRM; American Congress of Rehabilitation Medicine; Brain injuries; CRS-R; CTRS; Coma Recovery Scale–Revised; DOC; DVT; Diagnosis; ICF; ICU; ITB; IVC; International Classification of Functioning, Disability and Health; LE; LOS; MAS; MCS; Modified Ashworth Scale; NF; OT; PT; Prognosis; Rehabilitation; SLP; TBI; UE; US; UTI; VS; Vegetative state; certified therapeutic recreation specialist; deep vein thrombosis; disorders of consciousness; inferior vena cava; intensive care unit; intrathecal baclofen; length of stay; lower extremity; minimally conscious state; nursing facility; occupational therapist; physical therapist; speech-language pathologist; traumatic brain injury; ultrasound; upper extremity; urinary tract infection; vegetative state.