Disorders of Consciousness Program Maximizes Recovery for Patients with Brain Injuries

The Disorders of Consciousness (DoC) Program at TIRR Memorial Hermann provides state-of-the-art care for patients in an unresponsive wakefulness or minimally conscious state.

“We specialize in the diagnosis, management and treatment of patients with severe brain injuries who are clinically nonresponsive or considered to be in an unresponsive state,” notes Abana Azariah, MD, the Clinical Chief of the DoC Program at TIRR Memorial Hermann. “Most of these patients have a lot of physical restrictions that limit their ability to participate in traditional rehab therapy; therefore, they require DoC programs like ours, so that we can engage with them in a more specialized way.”’

Disorders of consciousness can arise from a variety of types of brain injuries, including traumatic brain injuries and injuries due to hypoxia, stroke or aneurysm rupture. The DoC Program at TIRR Memorial Hermann admits and treats patients regardless of the etiology of their injury.

“We believe every patient in a disorder of consciousness state— regardless of etiology—deserves a chance at accessing inpatient rehabilitation,” says Ryan Stork, MD, the medical director of the Brain Injury Program at TIRR Memorial Hermann. “We have more of a belief of at least providing access to these programs for the opportunity to demonstrate progress and then go from there.”

Patients with DoC have difficulty responding to or interacting with their environment to varying degrees. When a patient first comes to the TIRR Memorial Hermann DoC Program, a multidisciplinary care team works closely with them to characterize their ability to consistently respond to and interact with different stimuli. The team in the DoC Program works together to employ specialized interventions tailored to each patient’s specific needs.

“Often, what we find is when patients in an unresponsive wakefulness enter our program, our multidisciplinary therapy team, with neuropsychology and the physicians— we’re usually able to detect that they actually are conscious but often have difficulty demonstrating consciousness due to motor impairments or other neuromuscular deficits caused by their brain injury. For instance, a patient might know what we are asking for them to do, but may be unable to perform the task because of these neuromuscular impairments,” Dr. Stork explains. “The Disorders of Consciousness Program exists, outside of obviously helping the brain recover and giving intensive therapies for that… to identify, and as best as we’re able to, to eliminate any barriers that might be impairing a patient’s ability to respond in a meaningful way.”

A variety of hurdles may prevent a person from reaching their highest levels of consciousness and cognitive function. Medical hurdles may include hydrocephalus, which results from improper levels of cerebrospinal fluid around the brain, or spasticity, which prevents muscles from relaxing. Poorly managed seizures can affect patient responsiveness, which is also affected if a patient is on sedation medications. Sedating medications can hinder a person’s ability to engage with their environment.

“All too often, the assumption is that a patient’s brain is not working if they can’t move to respond to a question, that they’re not understanding what we’re asking them to do,” Dr. Stork says. “But in reality, they often do understand; it’s just that their body has motor impairments preventing them from responding the way that we’re asking them to. What the therapists and the multidisciplinary team here are incredibly helpful with is helping to tease that out. Sometimes it can take days to weeks for the therapy team to figure out what position the patient needs to be in in order to maximize their ability to move.”

“We identify and address any issues that could be impairing a patient’s consciousness,” Dr. Azariah adds. “We often find that some of the issues that impair their consciousness are reversible. We trial very specific interventions to help with recovery of consciousness. Interventions can include pharmacology, sensory interventions, cognitive assessments or behavioral assessments. We, of course, address any active medical issues, but we’re also very specialized in managing the common complications that can accompany these brain injuries.”

In addition to removing hurdles to communication, the DoC team at TIRR Memorial Hermann provides patients with pharmacologic treatments designed to stimulate brain function.

“We’re treating the body by addressing issues such as skin integrity, joint range of motion, tracheostomy care, PEG weaning, pain and positioning,” Dr. Azariah says. “We do this by developing formal sitting and standing programs, and bed positioning and wheelchair positioning protocols, for each patient. We know that verticalization enhances consciousness and improves wakefulness, therefore we try our best to get patients up and out of bed. In addition to our amazing therapy teams, we also have specialized teams like our wound care team, respiratory therapy team and nutrition team each bringing their expertise to the table. This comprehensive approach to the body sets our patients up for success.”

The DoC team is also focused on preserving patients’ minds by minimizing sedation and promoting wakefulness, through management of polypharmacy or by sensory stimulation, according to Dr. Azariah. Patients are also regularly evaluated in neurobehavioral assessments to “help us understand how they are responding from a cognitive standpoint and what their limitations may be,” she says.

“If they didn’t go to a DoC Program, many of our patients—possibly permanently, but definitely for months— would be left without a communication system,” Dr. Stork adds. “We’re developing a communication system for them, and this likely can’t be done in any other setting. That’s really, really valuable.”