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Interdisciplinary Brain Rehabilitation

Therapists utilize coma recovery scale, multi-discipline database to analyze recovery

Brain injury programs are expanding throughout the country but Spaulding Rehabilitation Network's disorders of consciousness (DoC) program is venturing into uncharted territory in standardizing their approach to these disorders. 
An integrated, multidisciplinary brain rehabilitation care program at Spaulding Boston and Spaulding Cambridge was designed for adults with severe acquired brain injury who have not recovered their ability to follow instructions, communicate or perform self-care. The program is open to patients in either long-term acute care or inpatient rehabilitation facilities. It's one of the few in the U.S. providing integrated multidisciplinary care throughout multiple levels. Though Spaulding has always treated minimally conscious patients, the arrival of Joseph Giacino, PhD, marked the initial development of the DoC program and systemized care. 

"The goal is to optimize functional recovery through the application of evidence-based assessment and treatment procedures in individuals with severe acquired brain injury in order to facilitate a means of communication for the patient," explained Denise Ambrosi, MS, CCC-SLP, CBIS, director of speech pathology. "With the implementation of a standardized approach, we are able to track subtle changes to optimize the patient's ability to communicate either verbally or non-verbally."
Progress is monitored weekly using a standardized battery of physical, cognitive, linguistic, motor and functional outcome measures designed specifically for persons with DoC. Clinical benchmarks derived from published research are used to guide decision-making regarding changes in treatment and discharge to the next level of care.

Since opening in March 2011, over 100 patients have been admitted to the DoC program across the two Spaulding facilities.  Many of the patients were transferred from the Cambridge to the Boston campus as the patients emerged from lower levels of consciousness, then were ultimately discharged to home, a skilled nursing facility or long-term care facility.

Classifying Consciousness
Using the Coma Recovery Scale-Revised (CRS-R), all patients in the Spaulding DOC program are classified in one of three care levels.

Level I focuses on those who have not recovered consciousness (vegetative state). Level II includes those who have recovered consciousness but are unable to communicate reliably (minimally conscious state). Level III patients can communicate but are confused and often unable to perform self-care activities.

According to Ambrosi and Anne Citorik, MS, CCC-SLP, CBIS, patients are admitted at any of the three levels. The clinicians use core metrics to measure changes in responsiveness and physical function, and document the patient's level of function in an electronic database at least biweekly. A neurobehavioral patient profile summary is generated to track subtle changes in consciousness and recovery of functionIt's also been a useful tool when communicating with insurance companies. 

"This is our patients' one chance at rehabilitation," explained Ambrosi. "If we can track their changes in responsiveness and determine whether they're able to utilize an augmentative communication system, it will help to refine the patient's rehabilitation goals and set an appropriate length of stay. If we can show that the patient is making consistent progress towards functional goals, we may be able to keep them longer."

Coma Recovery Scale
Another important metric is the Coma Recovery Scale (CRS-R), which is typically used only in major rehabilitation centers.At Spaulding, this scale is administered weekly by speech and also by physical or occupational therapists within the same time frame. This tool consists of 23 items assessing auditory, visual, motor, oromotor, communication and arousal functions. Subscales include hierarchically arranged items associated with brain stem, sub cortical and cortical processes. The lowest item represents reflexive activity and the highest item represents cognitively-mediated behaviors. Scoring is based on the presence or absence of operationally-defined behavioral responses to specific sensory stimuli. 

"The coma recovery scale is really best at picking up subtle changes over time," said Citorik. At Spaulding, the coma recovery scale is for level I and II patients. With level I patients, the goal is achieving level III with consistent communication. At this time, the team switches to a core measure called the confusion assessment protocol.

Cross Disciplinary Core Measurement
Part of the uniqueness of Spaulding's program is the cross-disciplinary teamwork. For instance, when patients need an AAC device, speech pathologists take the lead in determining readiness but OTs participate in the evaluation. Together, they review eye gaze systems and lower tech scanning switches. As patients working with switch devices start to progress and verbalize, the therapists re-evaluate together.

At a weekly meeting directed by Giacinio, quantitative assessments across speech, physical and occupation therapy are presented. Medication effectiveness is discussed at this juncture.

Should questions arise about a patient's visual function, individual assessments across the therapies are ordered.

"We use a systematic approach to determine if patients demonstrate consistency and accuracy of responses," said Ambrosi. "Systematic data collection allows for reliable analysis to guide assessment and treatment procedures."

A simple yes/no protocol determines consistency and accuracy for answering questions. Cognitive function is determined if the patients have high or low frequency, accurate and consistent responses.

For their part, OTs use a limb measurement protocol looking at physical mobility and disability rating scale on every patient in the program. The protocol was developed in-house at Spaulding. Family caregivers and nurses are engaged as well with strong handoff practices and clear documentation. 

"Here at Spaulding, we take off our discipline hat," said Ambrosi. "We are unique in that all of our protocols are administered across all disciplines."

Robin Hocevar is on staff at ADVANCE. Contact:


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