Specialized Brain Injury Treatment Helps Patients Emerge from Disorders of Consciousness
Too often, a tragic sense of futility affects the care of patients who are minimally conscious following a brain injury. Insurers may balk at paying for rehabilitation. Family members often despair that they have few choices and little hope.
That is why Shepherd Center researchers have carefully analyzed patient outcomes – and make the case for optimism. With specialized early treatment, many patients can emerge from a vegetative or minimally conscious state. They can communicate, regain some functional abilities or, in the most dramatic recoveries, eventually return to work or school, researchers report.
The promising outcomes stem from a comprehensive approach and the collaboration of a team of doctors, nurses and specialized therapists, says Ronald Seel, Ph.D., director of acquired brain injury research at Shepherd Center’s Virginia C. Crawford Research Institute. “Based on rehabilitation research and evidence, we’re able to put in place effective treatments that have been found to improve patient arousal, cognitive functioning and physical condition,” he says.
In the Shepherd Center Disorders of Consciousness (DOC) Program, 57 percent of patients arrive in a minimally conscious state, 41 percent are in a vegetative state and 2 percent are in a coma. The typical patient is a young male who was injured in a car accident and spent six weeks in an acute-care hospital before coming to Shepherd Center. The patient could not visually focus on his surroundings or respond to commands.
Patients in Shepherd Center's DOC Program receive acute medical care and at least 90 minutes of rehabilitation every day. Therapists stimulate patients to increase consciousness and improve their ability to communicate, and they work on physical mobility and range of motion. Physicians tailor medications to patient needs, often using amantadine hydrochloride, which has been shown to promote emergence from DOCs.
A review of 210 cases from 2005 to 2010 reveals the benefits of the specialized program. After an average of about five weeks, 53 percent of patients in the intensive program emerged from a minimally conscious state and were able to participate in traditional inpatient rehabilitation. Another 29 percent were able to return home to the care of their families. Only 13 percent transferred to a skilled nursing facility.
“This is a population that is at risk to languish in a nursing home if they didn’t come to Shepherd Center,” says Andrew Dennison, M.D., a Shepherd physiatrist who helps manage the care of patients with a disorder of consciousness. “People often get better when you provide the right environment and the right care and watch out for complications.”
The goal is to optimize recovery for each individual patient. While the challenges of each case differ, the approach to treatment is consistent. Shepherd Center has identified six common elements of care, a framework that is now informing the development of national standards of practice.
When a patient arrives at Shepherd Center, the immediate goal is to optimize the medical environment, starting with an accurate diagnosis using the Coma Recovery Scale-Revised (CRS-R). The care team addresses medical issues, works to wean the patient off a ventilator or tracheostomy collar, and reduces sedative use.
Patients can’t alert caregivers to pain or discomfort, so doctors and nurses are attentive. “We occasionally discover fractures, which were previously undiagnosed, from watching the patient more closely,” Dr. Seel says.
The medical team also works diligently to treat and prevent secondary medical conditions. When they arrived at Shepherd, 16 percent of DOC patients in the case review had pneumonia, 14 percent had urinary tract infections and 14 percent had pressure ulcers, or skin breakdown from lying immobile. Managing spasticity and spastic dystonia – a condition in which muscles contract and become rigid – requires daily intervention. About 45 percent of patients already had spasticity or another form of hypertonia of at least one arm or leg when they were admitted to Shepherd.
Maintaining bodily integrity is the third critical aspect of caring for patients with DOCs. Shepherd Center works to improve nutrition and manage bladder and bowel functions.
That sets the stage for the specialized care team’s work – improving functional communication and interaction with the environment and establishing functional mobility. Also an important facet of the program is family involvement, education and support. That ranges from hands-on training in caring for the patient to assistance in obtaining assistive devices or applying for Social Security disability payments.
By documenting the outcomes of the DOC Program, Shepherd researchers can give families a realistic, but hopeful assessment of their loved one’s prognosis, Dr. Seel explains.
The speed of progress is an important marker, says Jennifer Douglas, M.S., CCC/SLP, inpatient speech therapy manager, whose review of cases has helped guide the care of DOC patients. “If they make a certain gain within three weeks, then we know they are likely to go to rehabilitation while they’re here,” she says. “Other patients might take a little longer.”
Shepherd Center is expanding the registry to about 350 cases. Dr. Seel and his colleagues will continue to analyze cases to look for factors that improve the likelihood of emergence from a minimally conscious or vegetative state.
“It can help set some realistic expectations for our clinicians and families,” he says. “Maybe they believe a person isn’t advancing quickly enough. But if we look at their prognostic factors, maybe they’re doing as we would expect them to at that point in time.”
The registry is also a valuable tool for identifying promising medications. Physicians can try new treatments on a series of patients and compare their responses to similar patients from the registry who did not receive them, Dr. Seel says. “By doing this systemically using screening trials, we can determine whether the medications are helping people,” he adds.
One thing is already clear from the data: Many patients improve with a specialized, comprehensive program for disorders of consciousness. None of the patients had functional communication when they arrived at Shepherd Center. Upon discharge, one-third had functional and accurate communication, and 39 percent could move in response to a spoken command. Other patients had various levels of improvement.
“It shows the value of a program that has all of the right resources to be able to provide for this very challenging population,” Dr. Dennison says.
Written by Michele Cohen Marill
Photos by Gary Meek
Shepherd Center, located in Atlanta, Georgia, is a private, not-for-profit hospital specializing in medical treatment, research and rehabilitation for people with spinal cord injury, brain injury, multiple sclerosis, spine and chronic pain, and other neurological conditions. Founded in 1975, Shepherd Center is ranked by U.S. News & World Report among the top 10 rehabilitation hospitals in the nation. In its more than four decades, Shepherd Center has grown from a six-bed rehabilitation unit to a world-renowned, 152-bed hospital that treats more than 740 inpatients, nearly 280 day program patients and more than 7,100 outpatients each year in more than 46,000 visits.