This is a part of podcast series from the Model Systems Knowledge Translation Center on Disorders of Consciousness. Physical Therapist Beth Hansen explains how rehabilitation teams support communication as patients begin to emerge from a disorder of consciousness. 

In the beginning we're really focusing on activity tolerance, looking for that consistent behavior that we can engage in a communication style. And then as they start to emerge, we can see that they're command following or identifying objects. Those are two key components to us officially saying someone's starting to emerge from being in a minimally conscious state. So we're looking for those kind of behaviors and then really capitalizing on them to see if we can turn it into a communication tool; and then we're able to do a lot more with those patients. If they can consistently say yes/no, we can engage them in preferred activities. Even patients at that level of consciousness are more motivated or more participatory if it’s something they’re interested in doing.

Sometimes once patients have some movement, they might do it just kind of when they're resting in bed. So we observe that as well to make sure that the behavior that we're seeing is not just a resting behavior also. And then we actually quantify. We want a full thumbs up. So we're looking for that height of the thumb movement as opposed to more of like, do we see them almost rubbing their thumb or things like that because we need to have a definitive yes. This would be a yes, and then maybe a tuck would be a no. Or if they can do kind of a neutral or a thumbs down for an absolute no. That is so important to do. So a very clear thumbs up and a very clear neutral or a thumbs down if they can move their arm that much.  

The other things that we've done is do a switch. So if they have any movement in their arm that they can tap a switch for a yes and then tap it again for a no so that it's clear to us what they're actually trying to communicate. That is one thing that we've done. We've also done very simple things where we use an arm skate; so it has wheels and it takes away some of the friction; and we can say like, okay, you're going to move your arm to the right, to the no, and we'll have a visible cue for them. Move your arm to the left for a yes. And again, there'll be a visible cue for them, either the word or green for yes, red for no. Something along those lines.

I think that's important because we need to know they're really understanding kind of what we're requesting from them, and we may start to ask them some bigger questions if we are sure they're saying yes and no to us. So more things about treatment preference. Are they comfortable in their wheelchair? Do they want to do walking today or do they want to practice sitting … some things that will allow them to be more participatory and to engage them as the autonomous beings that we hope they'll get to, get back to being.

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