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Understanding the Spectrum of Traumatic Brain Injury
Interviewer: When most people hear traumatic brain injury, they think maybe a concussion, but there's actually a whole spectrum from mild to severe. And for the more complex cases, rehab can be the difference between simply surviving and truly recovering.
Today, we're talking about the more moderate to severe traumatic brain injury and a specialized area called disorders of consciousness, which includes patients in coma, unresponsive, and minimally conscious states.
I'm joined by Dr. Derrick Allred, associate professor in physical medicine and rehabilitation at the University of Utah Health and the brain injury medical director at the Craig H. Neilsen Rehabilitation Hospital.
Now, Dr. Allred, thank you so much for being here.
Dr. Allred: Thank you for having me.
Interviewer: Now, before we zoom in on our discussions about disorders of consciousness, why don't we start with a big picture? Because traumatic brain injury is used to describe a lot of very different injuries. So when we say traumatic brain injury, where does it start, and when does it start to become a disorder of consciousness?
Dr. Allred: As you stated in your introduction, the spectrum of severity across all traumatic brain injuries is quite vast, actually. So certainly on the more mild side . . . and we call mild just because of some of the deficits and some of the initial clinical presentations. Most of the public is familiar with what a concussion is. It's pretty mainstream.
When Brain Injury Leads to a Disorder of Consciousness
But if someone injures their brain or hits their head and it produces a more severe or more functionally impairing injury that includes some type of macroscopic damage to the brain, blood on the brain, swelling of the brain, lack of oxygen to the brain for an extended period of time, all of these can damage brain tissue to a much more severe degree.
And when we categorize the severity of TBI, it's usually across a classification system that identifies a mild versus a moderate versus a severe TBI. And those are distinctions that are based almost strictly off of whether or not the patient lost consciousness, whether or not the patient has resolved versus prolonged issues with their memory, or other types of deficits.
Certainly, as it relates to everyday functioning, such as walking, talking, dressing, our basic functions, the patients who sustain TBIs in the severe category tend to have much more pronounced difficulties in those areas.
Disorders of consciousness are a form of severe brain injury, though it doesn't have to necessarily be a traumatic brain injury. It is a condition that, after some type of brain insult or brain injury, their wakefulness, their awareness, and their ability to interact with their external or internal environment are significantly impaired. So disorders of consciousness, or you'll hear me allude to the term DOC, are potentially a form of traumatic brain injury that is severe.
The Three Main Types of Disorders of Consciousness
Interviewer: Why don't we go a little bit deeper into what a disorder of consciousness is and maybe where your team fits in all that?
Comatose
Dr. Allred: Under the umbrella of disorder of consciousness, there are further subclassifications. I think most people are familiar with the concept of a comatose patient or someone who is not awake, not able to interact with their environment whatsoever. They are, for all intents and purposes, "out cold."
Now, that is only one subcategory of disorders of consciousness. It's the most severe type. But when people sustain brain injuries, they rarely remain in that state indefinitely.
Unresponsive Wakefulness
There are two additional classifications. One is referred to as unresponsive wakefulness, or an older term, which people may be familiar with, a vegetative state.
This category identifies patients who, similar to being comatose, cannot interact with their environment whatsoever. They have no interpretation of what's going on inside of their body or outside, but they do wake up. In other words, they're awake, but they're not able to meaningfully understand or interact at all with what's going on around them.
Minimally Conscious State
And then the last classification of a disorder of consciousness is something we call a minimally conscious state. A transition from a vegetative state into a minimally conscious state implies that a patient is starting to have inconsistent and fluctuating wakefulness or meaningful interactions within their environment, but it's not sustained, it's not persistent. They'll kind of go in and out of consciousness.
How Patients Move Through Stages of Recovery
When someone has progressed through these different categories of consciousness, we use a term called emerged once a patient is starting to be able to meaningfully demonstrate that they can interact with their environment and they are, to some degree, able to be aware of their surroundings.
And so the intent of rehabilitation is to accurately identify these patients, accurately identify where they are along the spectrum of these disorders of consciousness, and to employ rehabilitation, pharmacologic, and environmental interventions to hopefully expedite their emergence into a clinical presentation in which they can more meaningfully interact with the therapy team.
And so that's the intent from a thousand-foot view of what a rehab team will do for these patients.
How Specialists Detect Signs of Consciousness
Interviewer: Understood. And just as, I guess, a layperson, what are some of the tests or methods that you use to kind of measure success with a patient suffering from a disorder of consciousness?
Dr. Allred: So clinically, we look for any type of signs that they are interacting with their environment. They can be as subtle as eye movement, fixating on a person as they go from one side of the room to another. They can be as subtle as a patient just trying to perform some type of communication through hand or finger gestures as they're starting to come to.
And as a clinical team is able to identify these signs, they can kind of lock onto them and employ therapeutic measures to try and help them recover more quickly.
There are standardized tests that we use to assess where they are along the spectrum, and we can do these tests in a serial nature, from day to day or from week to week, to see how they're progressing in certain areas of consciousness.
There's also technology, such as really fancy MRI machines and different things to those regards that can help, if an institution has them, maybe identify some form of consciousness.
But by and large, what a trained therapist or clinician in a DOC program can do is help identify, using the patient's premorbid, or what they were like before, things that they liked to do, using all that information about the person to see if we can identify when they're starting to regain that consciousness.
What a Disorders of Consciousness Rehab Program Offers
Interviewer: Whether it be another referring provider or maybe a family member of a patient, what is it about the disorders of consciousness program, this kind of specialty program that you have up at the Neilsen Rehabilitation Center? What does it offer that patients might not experience elsewhere?
Dr. Allred: One thing that's very unfortunate is that a standard rehabilitation patient, someone who is able to qualify for your typical regimen of inpatient rehabilitation, generally has to have what is termed meaningful participation to a certain level. We typically say that patients have to tolerate upwards of 3 hours a day, or 15 hours a week, of multidisciplinary therapy a day.
What's unfortunate about a patient who's in a disorder of consciousness is that one could look at these patients and say, "Well, they're not meaningfully interacting because they can't interact with their environment." So these patients aren't typically enrolled or admitted into an inpatient rehab program.
And there's evidence that suggests that the earlier we get these patients under the care of a team that can employ therapeutic interventions, the more successful we are at helping them recover.
There are some programs in the country that can and will admit these patients into a dedicated rehab program that's much more nuanced than what a standard inpatient rehabilitation course would look like.
We use anything and everything to help stimulate the patient, to help them rewire those neural networks, to help them wake up. We use multiple environmental techniques to try and stimulate their brain, such as music therapy, light therapy, aromatherapy, and things of that nature that go outside of just what you would get in a typical therapy session with physical, occupational, or speech therapy.
And then being treated under the care of a specialist, typically someone who is boarded in brain injury medicine and has experience in treating these patients, and knowing which therapeutic interventions to employ and in what time.
These are all things that go beyond what someone would typically see in a normal traumatic brain injury rehab program.
Who May Benefit From a Specialized DOC Program?
Interviewer: How do we determine whether or not a patient suffering from a disorder of consciousness would be a good fit for a program like yours? Because I know that these programs are not necessarily everywhere. They're still kind of rare here in 2026, but I'm trying to think more about that kind of system of care, that continuity of care. How do we determine, and how do we reach out to yours?
Dr. Allred: If there's a question, they should always ask and reach out and talk to us. That's the easy answer. Certainly, fielding a consult without actually physically interacting with the patient can pose challenges, but there are things that we can do and collaborate on with family members and providers outside of our system to help determine if they would be an ideal candidate for a program within a disorders of consciousness program.
Accurate Diagnosis Is Critical For Recovery Planning
Typically, there are a lot of misdiagnoses in the acute care setting and a lot of misinformation that's conveyed in terms of long-term prognosis with these patients.
If someone has sustained a traumatic brain injury to the degree to which they are persistently unconscious, then it's a good idea to consult us, or an experienced TBI provider to determine where they are along the spectrum so we can actually work to get them enrolled if at all possible.
Interviewer: Especially if your team is so willing to cooperate and collaborate with these other groups, that's fantastic.
And it's my understanding that if there is a clinician out there who thinks that maybe their patient might benefit from a program like yours, they can visit the Neilsen Rehabilitation website. Go to the link that we are going to include here, and there's a Refer a Patient button. Who typically handles kind of that initial point of contact? I'm sure you're not answering the phones.
Dr. Allred: So I'm not answering the phones, but specifically for this patient population, we have a general access team that fields all internal and external referrals. However, when we get a referral for a potential disorder of consciousness patient, I review every case.
For these patients, in order to maximize their success within a program such as this, there needs to be certain clinical features that have to be present before we would admit a patient to our service.
Not every patient who is comatose, for example, is an appropriate patient for a program like this. It's better to ask us, and we can weigh in. And if a patient is not appropriate for admission to a formal program such as ours, then we certainly can lend additional clinical guidance and recommendations on how to continue to care for them.
Supporting Families Through Severe Brain Injury
Interviewer: I did an interview before, and the idea was that traumatic brain injury doesn't just happen to one person, right? Disorders of consciousness don't happen to one person either. How do you and your team help to, say, support the families, the other people in the room?
Dr. Allred: I think first and foremost, one of the best ways to provide service to these families and loved ones is to give them a sense of hope, and that hope stems from an accurate diagnosis of where these patients actually stand.
I think striking a balance between providing education in a way that's digestible and understandable, without overwhelming families, and also not robbing them of the hope that is needed to help them get through these very challenging times when their loved ones are injured.
In addition to that, education and knowledge are power. We pride ourselves here on providing the very best and most up-to-date and accurate education that can help prepare families for what to expect with these patients, both in the short-term and potentially in the long-term, depending on how their clinical trajectory progresses.
Between providing accurate medical information and treatment interventions and providing quality education, there's also the importance of resource utilization and hearing out what immediate and long-term resources are available, how to start those processes early, whether it's financial aid, equipment resources, or whatever it may be.
We start planning for these things early on so that we can set families up for success, irrespective of how much recovery is had with their loved one or these patients. Some make remarkable recoveries, others not so much.
But regardless of where someone stands at the end of a rehabilitation course, we want to empower families with the ability to not only care for their loved ones and their basic needs, but to have meaningful lives when they leave our care.
Craig H. Neilsen Rehabilitation Hospital
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