Dr. Luís Malaia

Specialist Physiatrist
Coordinator of the Rehabilitation Unit

Dr. Miguel Coutinho

Neuropsychologist

 

Disorders of consciousness (doc) rehabilitation program

HPA Magazine 5

The Rehabilitation Program for Disorders of Consciousness (DOC) is a specialized service integrated as a continuum of the differentiated health care provided by the Hospital Particular do Algarve Group directed at patients with “severe acquired brain injury”. 
These specialized treatments aim to recover the functionality and capacity to follow instructions, to communicate and to carry out daily activities.

Patients and their families are offered continuous support and structured rehabilitation at this state of the art Unit, carried out by an interdisciplinary team of skilled professionals with specialized training in Disorders of Consciousness (DOC) in accordance with the international guidelines of the Royal College of Physicians. 
Early treatment by the Rehabilitation Program Team for DOC helps to maximize the possibility of clinical and functional recovery in the short, medium and long term.
Rehabilitation at this stage is focused essentially in facilitating the patient’s progress when emerging from disorders of consciousness (following simple commands/orders directed at objects or parts of the body for example, while maintenance of vigilance. 
Prospective studies in DOC patients with functional clinical conditions, have confirmed the importance of rehabilitation treatment when it is begun in its acute phase and continued throughout the recovery process. This is demonstrated through various indicators, better results (prevention of motor complications and functional improvement both motor and cognitive).
Several prospective studies on the Rehabilitation Program on Consciousness Disorders have indicated promising results on hospital discharge, for patient who received early and specialized treatment, based on the criteria of following simple commands, as well as improvement on cognitive function in the follow up period after brain injury (1,2 and 5 years). 

CONSCIOUSNESS
Consciousness can be into two distinct main areas: 
Arousal: spontaneous eye opening and basic reflexes such as coughing, swallowing; 
Awareness: obeying commands, memories, planning and communicating;
DOC is a clinical condition with different aetiologies. Its duration can be short (seconds, minutes or hours), transient (days or weeks after severe brain injury) or chronic (remaining stable over time).

LEVELS OF CONSCIOUSNESS
The guidelines of the Multi-Society Task Force on Persistent Vegetative State and Aspen Workgroup refer 3 levels of Disorders of Consciousness: 
Coma: absence of wakefulness and absence of awareness;
Vegetative State (VS) or Unresponsive Wakefulness Syndrome (UWS): wakefulness with absence of awareness; 
Minimally Conscious State (MCS): wakefulness with minimal awareness. Some patients will not emerge from a vegetative or minimally conscious state. 

CAUSES
The most common causes of “Brain Injury”, which can result in DOCare:

• Traumatic Brain Injury;
• Stroke;
• Cerebral Anoxia; 
• Infections; 
• Intoxication (drugs/alcohol).

THE TEAM APPROACH 

• Consultant in Physiatry, Internal Medicine and other Medical Specialties;
• Nurse;
• Physiotherapist; 
• Ocupational Therapist; 
• Speech Therapist; 
• Neuropsychologist / Psychologist; 
• Dietitian.

ASSESSMENT AND SPECIALIST INTERVENTION 

• Assessment, diagnosis and monitoring of the level of consciousness and functional clinical condition (Magnetic Resonance Imaging MRI; Evoked Potentials Electroencephalogram (EEG);
• Psychoeducation and emotional support for the family or caregivers; 
• Medication for enhancing wakefulness and behaviour regulators;
• Neuromodulation;
• Motor Sensory regulation; 
• Sensory Stimulation.

THE PROGRAMME IS AIMED AT THREE DIFFERENT FUNCTIONAL STATUS

• For those patients who have as yet not recovered consciousness;
• For those that have recovered consciousness but cannot as yet communicate functionally effectively;
• For those that despite having achieved functional communication, remain confused and continue to need assistance in carrying out daily activities.

OUR PROGRAMME AIMS TO

• Determine levels of consciousness using assessment protocols based on evidence;
• Identify physical and cognitive barriers within the surrounding environment and functional communication skills;
• Mark the prognosis and to monitor functional clinical evolution;
• Plan ahead the need of long-term support;
• Prevent secondary complications (contractures, skin lesions and infections):
• Maximize the level of alertness and response using drug therapy, technology and cognitive behavioural stimulation protocols; 
• Maximize the ability to perform daily activities;
• Provide psycho education, support for patients, families and other caregivers; 
• Enable the participation in new approach of evaluation and intervention techniques (still being studied in the clinical and academic field).

The integration of patients in these programs contributes to the improvement of the patient’s state of consciousness and response to the surrounding environment maximizing the patient’s professional and social reintegration as well as within the family.