This is a part of podcast series from the Model Systems Knowledge Translation Center on Disorders of Consciousness. Dr. Joseph Giacino explains how specialized inpatient rehabilitation helped uncover the cause of Hannah’s slow language recovery after a disorder of consciousness. 

Hannah was really one of the lucky ones, if you will, who make it into inpatient rehab — that 15% or so — and good thing that she was admitted because she had a very complicated injury and a complicated course. 

I first saw Hannah when she was four weeks post-injury. At that point, she was awake, but she only had a single sign of consciousness, and that was visual tracking, the ability to follow persons or objects with her eyes, but not able to follow any simple instructions … not speaking, not gesturing, really no other sign of consciousness except for that. So it is the lowest limit of what we would consider conscious awareness.  

The longer one shows no recovery, the less likely that one will be to recover lots more function down the line. But she was not one of those individuals. So what ended up happening with Hannah is that despite her really protracted period where she was literally months in that state, she then started to show slow progressive improvement where more and more signs of consciousness started to return.

So we were systematically evaluating her so we could see that despite subtle observable changes, she was making important improvements because we were seeing behaviors reemerging that we could document in a progressive way. And that's changed her prognosis. The fact that she went a long time without recovering commands was mitigated to some extent by the fact that she was demonstrating other improvements.

And she got to the point where there was an interesting disparity or difference between what she was doing behaviorally and her ability to follow instructions or to communicate. So those language signs were still lagging behind the rest of her recovery. So when we see that, that might be an indication that the language system was damaged and the person has what's called aphasia, where they're unable to comprehend speech and/or express language.

So we did entertain that possibility, but Hannah really didn't have, if we looked at her imaging, didn't look like the left hemisphere, which is the seat for language, was compromised in a way that we would expect for somebody to have aphasia. Yet that disparity continued. She got to the point where she was using objects in a functional manner. She was initiating behaviors, indicating her wants and needs, but not through speech and not following instructions. So then she got to the point at about three or four months then where she did start to get some single words out. And when she began to be able to express her thoughts, which were very rudimentary, she indicated she was having trouble hearing. So we thought, well, maybe that is the problem. So she was sent to, she saw audiologists, she saw other specialists, and no hearing impairment could be found.

But she then went on to have additional exams, including by neurology, and we looked very carefully back at the imaging; and it turns out that she had injury to a part of the midbrain that is part of the auditory pathway. So it is likely that her hearing problem was not an auditory problem, but was a brain processing problem where this disconnection, I talked about this before, occurred low down in the brain, a key node or structure in that pathway that a sound has to sort of travel up and get to the cortex in order to be fully processed was disrupted by this lesion in the midbrain, and compromised her ability to process spoken language. That got better, to the point that she can have a conversation with Hannah now.  

That's what we do in an inpatient rehab setting. That's not going to happen in a long term, uh, you know, skilled nursing facility. They're not equipped to do that. I don't think that would have been discerned in a non-specialized center that she had, this is called the central auditory processing disorder. It takes a lot of specialized knowledge and technique to be able to diagnose that problem and understand why she was doing well behaviorally or functionally, but still was having trouble following simple instructions and even expressing speech. 

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