Studies have shown that 35 to 40 percent of patients with disorders of consciousness (DOC) are misdiagnosed and undertreated. Frequently thought of as vegetative, many are either conscious or minimally conscious.
"These are patients with severely impaired consciousness as a result of acquired brain injury or insult, most often traumatic brain injury or anoxic injury,” says Sunil Kothari, MD, an attending physician at TIRR Memorial Hermann and assistant professor of physical medicine and rehabilitation at Baylor College of Medicine. “One definition of consciousness is awareness of self and the environment. Patients with disorders of consciousness range from those who are just coming out of coma but are still in a vegetative state, to those in a minimally conscious state. Traditional forms of rehabilitation were not considered appropriate for this group because of their impaired consciousness.”
Increased awareness of the heterogeneity of patients with disorders of consciousness, new knowledge of the condition, and improved methods of assessment and treatment have led to the formalization of the DOC program at TIRR Memorial Hermann. “We now have a greater understanding of the different states in disorders of consciousness,” Dr. Kothari says. “As a community of rehabilitation clinicians and researchers, we’ve made significant improvements in our ability to assess at the bedside and detect states of consciousness that in the past would have been missed. Newer technology-based assessment tools such as functional MRI imaging, PET scans and neurophysiological studies have enabled us to better understand the neuroanatomical bases of these disorders. This understanding has led to new developments in treatment. Medications have been found to facilitate the recovery of consciousness in some patients. Some researchers are looking at the potential of deep brain stimulation to help these patients return to consciousness."
Physical therapist Julie Welch, PT, NCS, says TIRR Memorial Hermann has been working with patients with DOC since 1999. “The evolution of the program has tracked alongside increased understanding of these conditions in the academic world. At each stage, as we’ve learned to distinguished differences in disorders of consciousness, we’ve incorporated the knowledge into a more formalized program."
Newer technology-based assessment tools such as functional MRI imaging, PET scans and neurophysiological studies have enabled us to better understand the neuroanatomical bases of these disorders.
Specialized training is required to perform assessments of patients with DOC. Next steps at TIRR Memorial Hermann involve educating all members of the care team. Case managers at the rehabilitation hospital are also at the forefront of working with insurance companies to demonstrate a strong rationale for covering the cost of care of these patients.
“We’re hoping that this new knowledge will encourage insurance carriers to pay for care, and that our outcomes will reinforce that trend,” Welch says. “After assessing patients, we make recommendations for the next best steps. If patients need a medical procedure or if they advance to a different level of care, our team will follow them after discharge to ensure that they are assessed for appropriateness for return to rehabilitation. In addition to expanding the care they receive at TIRR Memorial Hermann, we want to ensure a strong continuum of care through all stages of recovery.”