A Systematic and Evidence-Based Approach to Clinical Management of Patients with Disorders of Consciousness

  • Joseph T. Giacino
  • Christopher G. Carter
  • Carrie Charney
  • Denise Ambrosi
  • Matthew J. Doiron
  • Seth Herman
  • Timothy Young
Part of the Clinical Handbooks in Neuropsychology book series (CHNEURO)


Disorders of consciousness include coma, the vegetative state, the minimally conscious state and the post-traumatic confusional state. These conditions exist along a two-dimensional continuum comprised of arousal (i.e., wakefulness) and awareness (i.e., recognition of self and environment). Accurately characterizing and distinguishing these disorders early after onset is critically important as diagnosis is closely linked to prognosis and drives clinical decision-making. Unfortunately, published rates of misdiagnosed consistently approach 40 % with most of the error accounted for by failure to detect consciousness when it is preserved. Misdiagnosis may limit access to medical and rehabilitation services and lead to premature withdrawal of life-sustaining care. In this chapter, we describe a systematic, evidence-based framework for clinical management of patients with DoC. The primary aim is to demonstrate how a standardized, multi-tiered approach to assessment organized around a structured “care map” can be instituted in the rehabilitation setting to inform diagnostic, prognostic and treatment decisions, ultimately improving the consistency and effectiveness of care.


Vegetative state Minimally conscious state Rehabilitation Neuropsychology Assessment Outcome measure 


  1. 1.
    Faul, M. X. L., Wald, M. M., & Coronado, V. (2010). Traumatic brain injury in the United States: Emergency department visits, hospitalizations and deaths, 2002-2006. Atlanta, GA: National Center for Injury Prevention and Control.Google Scholar
  2. 2.
    Posner, J. B., & Plum, F. (2007). Plum and Posner’s diagnosis of stupor and coma (4th ed., Vol. 14, 401p.). Oxford, England: Oxford University Press.Google Scholar
  3. 3.
    Multi-Society Task Force on PVS. (1994). Medical aspects of the persistent vegetative state (1). The New England Journal of Medicine, 330(21), 1499–1508.CrossRefGoogle Scholar
  4. 4.
    Quality Standards Subcommittee of the American Academy of Neurology. (1995). Practice parameters: Assessment and management of patients in the persistent vegetative state (summary statement). Neurology, 45(5), 1015–1018.CrossRefGoogle Scholar
  5. 5.
    Giacino, J. T., Ashwal, S., Childs, N., Cranford, R., Jennett, B., Katz, D. I., et al. (2002). The minimally conscious state: Definition and diagnostic criteria. Neurology, 58(3), 349–353.PubMedCrossRefGoogle Scholar
  6. 6.
    Sherer, M., Nakase-Thompson, R., Yablon, S. A., & Gontkovsky, S. T. (2005). Multidimensional assessment of acute confusion after traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 86(5), 896–904.PubMedCrossRefGoogle Scholar
  7. 7.
    Sherer, M., Yablon, S. A., Nakase-Richardson, R., & Nick, T. G. (2008). Effect of severity of post-traumatic confusion and its constituent symptoms on outcome after traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 89(1), 42–47.PubMedCrossRefGoogle Scholar
  8. 8.
    Childs, N., Mercer, W., & Childs, H. (1993). Accuracy of diagnosis of persistent vegetative state. Neurology, 43(8), 1465–1467.PubMedCrossRefGoogle Scholar
  9. 9.
    Andrews, K., Murphy, L., Munday, R., & Littlewood, C. (1996). Misdiagnosis of the vegetative state: Retrospective study in a rehabilitation unit. BMJ, 313(7048), 13–16.PubMedCentralPubMedCrossRefGoogle Scholar
  10. 10.
    Schnakers, C., Vanhaudenhuyse, A., Giacino, J., Ventura, M., Boly, M., Majerus, S., et al. (2009). Diagnostic accuracy of the vegetative and minimally conscious state: Clinical consensus versus standardized neurobehavioral assessment. BMC Neurology, 9, 35.PubMedCentralPubMedCrossRefGoogle Scholar
  11. 11.
    Giacino, J. T., Schnakers, C., Rodriguez-Moreno, D., Kalmar, K., Schiff, N., & Hirsch, J. (2009). Behavioral assessment in patients with disorders of consciousness: Gold standard or fool’s gold? Progress in Brain Research, 177, 33–48.PubMedCrossRefGoogle Scholar
  12. 12.
    Dejong, G., Horn, S. D., Gassaway, J. A., Slavin, M. D., & Dijkers, M. P. (2004). Toward a taxonomy of rehabilitation interventions: Using an inductive approach to examine the “black box” of rehabilitation. Archives of Physical Medicine and Rehabilitation, 85(4), 678–686.PubMedCrossRefGoogle Scholar
  13. 13.
    Lammi, M. H., Smith, V. H., Tate, R. L., & Taylor, C. M. (2005). The minimally conscious state and recovery potential: A follow-up study 2 to 5 years after traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 86(4), 746–754.PubMedCrossRefGoogle Scholar
  14. 14.
    Katz, D. I., Polyak, M., Coughlan, D., Nichols, M., & Roche, A. (2009). Natural history of recovery from brain injury after prolonged disorders of consciousness: Outcome of patients admitted to inpatient rehabilitation with 1-4 year follow-up. Progress in Brain Research, 177, 73–88.PubMedCrossRefGoogle Scholar
  15. 15.
    Estraneo, A., Moretta, P., Loreto, V., Lanzillo, B., Santoro, L., & Trojano, L. (2010). Late recovery after traumatic, anoxic, or hemorrhagic long-lasting vegetative state. Neurology, 75(3), 239–245.PubMedCrossRefGoogle Scholar
  16. 16.
    Nakase-Richardson, R. W. J., Giacino, J. T., et al. (2012). Longitudinal outcome of patients with disordered consciousness in the NIDRR TBI model systems programs. Journal of Neurotrauma, 29(1), 59–65.PubMedCrossRefGoogle Scholar
  17. 17.
    Giacino, J. T., Kalmar, K., & Whyte, J. (2004). The JFK Coma Recovery Scale-Revised: Measurement characteristics and diagnostic utility. Archives of Physical Medicine and Rehabilitation, 85(12), 2020–2029.PubMedCrossRefGoogle Scholar
  18. 18.
    DiPasquale, M. C. W. (1996). J. The use of quantitative data in treatment planning for minimally conscious patients. The Journal of Head Trauma Rehabilitation, 11(6), 9.CrossRefGoogle Scholar
  19. 19.
    Schnakers, C., Majerus, S., Giacino, J., Vanhaudenhuyse, A., Bruno, M. A., Boly, M., et al. (2008). A French validation study of the Coma Recovery Scale-Revised (CRS-R). Brain Injury, 22(10), 786–792.PubMedCrossRefGoogle Scholar
  20. 20.
    Lovstad, M., Froslie, K. F., Giacino, J. T., Skandsen, T., Anke, A., & Schanke, A. K. (2010). Reliability and diagnostic characteristics of the JFK Coma Recovery Scale-Revised: Exploring the influence of rater’s level of experience. The Journal of Head Trauma Rehabilitation, 25(5), 349–356.PubMedCrossRefGoogle Scholar
  21. 21.
    Rappaport, M., Hall, K. M., Hopkins, K., Belleza, T., & Cope, D. N. (1982). Disability rating scale for severe head trauma: Coma to community. Archives of Physical Medicine and Rehabilitation, 63(3), 118–123.PubMedGoogle Scholar
  22. 22.
    American Speech-Language-Hearing Association. (2003). National Outcomes Measurement System (NOMS): Adult speech-language pathology user’s guide. Rockville, MD: Author [Internet].Google Scholar
  23. 23.
    Strauss, E., Sherman, E. M. S., Spreen, O., & Spreen, O. (2006). A compendium of neuropsychological tests: Administration, norms, and commentary (3rd ed., Vol. xvii). Oxford, England: Oxford University Press. 1216p.Google Scholar
  24. 24.
    Schiff, N. D., Giacino, J. T., Kalmar, K., Victor, J. D., Baker, K., Gerber, M., et al. (2007). Behavioural improvements with thalamic stimulation after severe traumatic brain injury. Nature, 448(7153), 600–603.PubMedCrossRefGoogle Scholar
  25. 25.
    Whyte, J., Nordenbo, A. M., Kalmar, K., Merges, B., Bagiella, E., Chang, H., et al. (2013). Medical complications during inpatient rehabilitation among patient with traumatic disorders of consciousness. Archives of Physical Medicine and Rehabilitation, 94(10), 1877–1883.PubMedCrossRefGoogle Scholar
  26. 26.
    Sander, A. M. (2007). Brain injury and the family. NeuroRehabilitation, 22(1), 1–2.Google Scholar
  27. 27.
    Sinnakaruppan, I., & Williams, D. M. (2001). Family carers and the adult head-injured: A critical review of carers’ needs. Brain Injury, 15(8), 653–672.PubMedCrossRefGoogle Scholar
  28. 28.
    Gan, C., Campbell, K. A., Gemeinhardt, M., & McFadden, G. T. (2006). Predictors of family system functioning after brain injury. Brain Injury, 20(6), 587–600.PubMedCrossRefGoogle Scholar
  29. 29.
    Bond, A. E., Draeger, C. R., Mandleco, B., & Donnelly, M. (2003). Needs of family members of patients with severe traumatic brain injury. Implications for evidence-based practice. Critical Care Nurse, 23(4), 63–72.PubMedGoogle Scholar
  30. 30.
    Teasdale, G., & Jennett, B. (1974). Assessment of coma and impaired consciousness. A practical scale. Lancet, 2(7872), 81–84.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2014

Authors and Affiliations

  • Joseph T. Giacino
    • 1
    • 2
    • 3
    • 4
  • Christopher G. Carter
    • 1
    • 5
    • 4
  • Carrie Charney
    • 1
  • Denise Ambrosi
    • 1
  • Matthew J. Doiron
    • 1
  • Seth Herman
    • 1
    • 5
  • Timothy Young
    • 1
    • 5
  1. 1.Spaulding Rehabilitation HospitalCharlestownUSA
  2. 2.Department of Physical Medicine and RehabilitationHarvard Medical SchoolBostonUSA
  3. 3.Department of Physical Medicine and RehabilitationMassachusetts General HospitalBostonUSA
  4. 4.MGH Institute for Healthcare ProfessionalsBostonUSA
  5. 5.Harvard Medical SchoolBostonUSA

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