The Spaulding Rehabilitation Network (SRN) Disorders of Consciousness Program was developed to provide a continuum of care specifically designed for individuals who have experienced severe acquired brain injury and have not yet regained the ability to follow instructions, communicate reliably, or perform basic self-care activities. The marked variability in the physical, cognitive, behavioral, and emotional sequelae of severe brain injury suggests that a one-size-fits-all model of rehabilitation is likely to be ineffective. In the remainder of this chapter, we describe a specialized 8-week program in which assessment and treatment procedures are standardized and administered systematically by a multidisciplinary neurorehabilitation team.

The 8-week SRN DoC Program is organized into three levels of care, each intended to address the clinical needs of patients functioning at different levels of consciousness. Program services are initiated and modified based on level-specific criteria. Level I focuses on individuals who have not yet recovered consciousness and whose level of functioning is consistent with coma or the vegetative state. Patients admitted to Level I are either unarousable or demonstrate fluctuations in arousal and display no command-following, purposeful movement, or communication ability. The Coma Recovery Scale-R (CRS-R) [17] (see description under section “Core Metrics”) is the primary assessment measure used at this level to track neurobehavioral recovery and monitor response to interventions. Behavioral and pharmacologic protocols are commonly employed to facilitate arousal at this level. Level II focuses on patients in the MCS who show clear but inconsistent evidence of conscious awareness, are unable to communicate reliably, and require maximum assistance for basic care. The transition from Level I to Level II requires demonstration of at least one feature of MCS on three consecutive CRS-R exams. The CRS-R and Individualized Quantitative Behavioral Assessment (IQBA) protocols [18], which rely on single-subject research methodology to investigate case-specific questions, are the key assessment procedures used at this level. Therapies designed to foster response consistency, augmentative communication, and environmental control strategies are typically initiated at this level. Level III focuses on individuals in the posttraumatic confusional state. Patients in PTCS are alert and have regained the ability to communicate reliably, but remain confused and highly distractible, often with sleep disturbance, impulsivity, and agitation. Progression to Level III is achieved once reliable yes–no responses are demonstrated across three consecutive CRS-R exams. The primary assessment measure used in Level III is the Confusion Assessment Protocol (CAP) [6], which monitors seven cardinal signs associated with acute confusion (see description in section “Core Metrics”).

In order to institute a systematic approach to care and maintain adherence to the program timeline, a specialized DoC Care Map was developed. The Care Map is divided into two sections. The discipline-specific section details the clinical services for which each rehabilitation specialist on the team is responsible. In contrast, the interdisciplinary section displays the activities that are shared by all team members. The Care Map specifies the timing of all assessment, treatment planning, and educational activities that are administered over the course of the 8-week program. The primary aim of the Care Map is to ensure that all components of the program are administered systematically and in accord with the pre-arranged timeline. Table 2 shows the interdisciplinary section of the DoC Program Care Map.

Assessment and treatment interventions are provided by a multidisciplinary team comprised of specialists in neuropsychology, physiatry, nursing, physical therapy, occupational therapy, speech language pathology, social work, case managers, and other specialists as appropriate. On admission to the DoC Program, participants undergo a standardized assessment carried out jointly by all members of the team. A comprehensive battery of “core metrics,” referred to as the “DOC COMPASS” (i.e., Disorders of Consciousness COMPrehensive ASSessment Battery), is administered to establish a functional baseline across multiple domains. Some of the core metrics are administered by all members of the team, while others are assigned to particular disciplines, based on expertise. A fixed assessment schedule has been established with the frequency of administration varying by measure. Table 3 provides a summary of the core metrics and corresponding assessment schedule.