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- Altered state of consciousness

-A deep state of unconsciousness where a person does not consciously respond to external stimuli

-Coma can be brief or last for weeks at a time (patient is completely out)

-Occurs secondary to an underlying neurological condition or traumatic brain injury

-Patients are sometimes placed in a medically induced coma

1. Can't open eyes
2. No communication
3. Can't follow directions
4. No purposeful movement


Vegetative State

-Patient has lost cognitive abilities and awareness of surroundings; will maintain normal sleep-wake cycles

-Spontaneous movements may occur and even include crying, laughing, or grimacing;

-Patients may open their eyes to external stimuli

-Vegetative State → Persistent Vegetative State @ 1 month

Reflexive pain test:
Sternal rub (take knuckles and rub against sternum) trying to inflict pain to see if there has been a change (see if there is a response)

Twist and pinch the side of the patient to see if they will respond to pain

Nail bed press- press on nail bed

2. No communication
3. Can't follow directions
4. No purposeful movement


Minimally Conscious State

-MCS references those patients that exhibit a slow recovery of consciousness; continue to have poor self-awareness as well as awareness of the world around them

-Patients may intermittently follow directions; communicate y/n via gestures or vocalizations; may use some recognizable words + phrases

-May reach for objects or try to hold an object; focus on items or people for longer periods of time

****Patients are very inconsistent!

Looks like they are present but their level of consciousness is impaired

Vegetative state
Minimally Conscious State


Common characteristics:

1. Coma

2. Vegetative State

3. Minimally Conscious State

1. Coma- NO- eye opening, sleep wake cycles, visual tracking, object recognition, command following, communication, contingent emotion

2. Vegetative State- Have: eye opening, sleep wake cycles

NO: visual tracking, object recognition, command following, communication, contingent emotion

3. Minimally Conscious State-
Have: eye opening, sleep wake cycles

Often: visual tracking

Inconsistent: object recognition, command following, communication, contingent emotion


Timeline for consciousness
1. Time of injury
2. 2 weeks
3. 4 weeks
4. 6 weeks
5. 8 weeks
6. 10 weeks

1. Coma
2. Coma
3. Vegetative state
4. Vegetative state
5. Persistent vegetative state
6. Minimally responsive state

Longer they are in a coma, longer they have LOC- the greater the brain injury


TBI Severity Ratings

-Patients may be classified as having a mild, moderate, or severe traumatic brain injury based on their level of consciousness

-There are three rating scales commonly used to assess severity

3 rating scales:
1. Glasgow Coma Scale
2. Post Traumatic Amnesia
3. Ranchos Los Amigos Scale of Cognitive Functioning


Glasgow Coma Scale

-Teasdale and Jennette in 1974, 1976

-Estimation of the depth of coma as a measure of severity within the first 24h of the trauma

-Patient is assigned a score between 3-15 (3 is the lowest); points are assigned per BEST eye opening (1-4), BEST motor response (1-6), and BEST verbal response (1-5); the > the score the more conscious the person

Issue- designed for adults so the criteria of the GCS is not great for babies

Pencil/pen/ clicker has a GCS of 3


Glasgow Coma Scale Severity Ratings

-Adult version

-Modified Pediatric Version

Severity Ratings:

Mild TBI- Total score between 13-15

Moderate TBI- Total score between 9-12

Severe TBI-Total score between 8-3


Decorticate Flexion

Decorticate posture results from damage to one or both corticospinal tracts. In this posture, the arms are adducted and flexed, with the wrists and fingers flexed on the chest. The legs are stiffly extended and internally rotated, with plantar flexion of the feet.

- Posturing is never good


Decerebrate Extension

- Worse than decorticate because there is damage to the upper brainstem.

-Decerebrate posture results from damage to the upper brain stem. In this posture, the arms are adducted and extended, with the wrists pronated and the fingers flexed. The legs are stiffly extended, with plantar flexion of the feet.


Post Traumatic Amnesia (Duration Focus)

-PTA may be used as an alternative to the GCS (Russell, 1932)

- PTA- helps us rate the degree of TBI

-PTA: References the period to time where the Patient has regained consciousness but is still in a disoriented and confused state and until the time the Patient’s memory for ongoing events becomes reliable and accurate

-Mild TBI- Period of coma + PTA < 1 hour

-Moderate TBI- Period of coma + PTA is 1-24 hours

-Severe TBI- Period of coma + PTA is 1-7 days

- Profound TBI- Period of coma + PTA is 7+ days


Response Progression

-Patients may progress through several types of responses during recovery from a state of altered consciousness

Highest--> Most functional
1. Deepest stage
2. Reflexive Behaviors
3. Generalized Responses
4. Localized Responses
5. Physiological Responses


Responses Defined

1. Deepest Stage- Patient is totally unresponsive to any stimuli including painful or aversive types

2. Reflexive Behaviors- Patient exhibits production of unconscious, subcortical reflexive behaviors; may return to primitive behaviors (Hux, p. 82-83) munching is bad

3. Generalized Response- Stimulation triggers movement of a body part not associated with the actual stimulus; a noise in the room may trigger a chewing response (apply pain to the finger, patient moves their leg)

4. Localized Response- Noise occurs in the room, Patient turns toward stimulus (pull away from area that pain)

5. Physiological Response-Stimulus triggers change in BP, RR, O2, Temp, Pupils (change in the body)

***Know the difference between generalized and localized responses


Ranchos Scale

-The RLAS provides a way to describe cognitive functioning from the early stage of injury through to the later stages of recovery

-Patient is assigned a level based on their presentation using # I-X

Levels I-III (severe deficits)

Levels IV-VI (moderate deficits)

-Ranchos scale can change, SLP may be different than PT if it is a different time of day (patient could have a ranchos scale consistent of a 4-5)

-A patient that has a concussion (mTBI) will have a RLAS of VII-X

-Levels VII-X (milder deficits)


Ranchos Scale

1. Levels (I-III)

2. Levels (IV-VI)

3. Levels (VII-X)

1. Levels (I-III)- Patients present as comatose or emerging from a coma; may be categorized as in a persistent vegetative state or minimally conscious state

2. Levels (IV-VI)- Patients present as beginning the process or regaining orientation + memory skills necessary for full consciousness

3. Levels (VII-X)-Patients present with persistent cognitive, social, and emotional challenges

-The difference between RLAS 3-5 is huge

-Ranchos level 4- patient is very combative, they will say inappropriate things and be mean, but stress to the family that the patient is getting better.

-Ranchos 4 does not last long (not always appropriate for therapy at this point)


Ranchos I

- Ranchos I- No Response

- Unresponsive to any stimuli


Ranchos II

- Ranchos II- Generalized Response

- Non-purposeful responses; Responds usually to pain only


Ranchos III

- Ranchos III- Localized Response

- Purposeful; May follow simple commands


Ranchos IV

- Ranchos VI- Agitated/ Confused

- Confused; Disoriented; Agitated; Aggressive; Combative; Unable to perform self-care


Ranchos V

- Ranchos V- Confused/ Inappropriate

- Non-agitated; Appears alert; Responds to commands; Does not learn; Verbally inappropriate


Ranchos VI

- Ranchos VI- Confused/Appropriate

- Can relearn old skills; Serious memory deficits; Some awareness of others and self


Ranchos VII

- Ranchos VII- Automatic/Appropriate

-Oriented; Robot-like ADLs; Minimal confusion; Lacks insight into planning ability


Ranchos VIII

- Ranchos VIII- Purposeful/Appropriate

-A&O (alert and orientated); Independent in living skills; Capable of driving; Deficits may persist for judgment; Skills ∅ premorbid


Ranchos IX

-Ranchos IX- Purposeful and appropriate

-Stand-by on request; (I)ly shifts back/forth between tasks with good accuracy for at least 2h


Ranchos X

- Ranchos X- Purposeful/ Appropriate

-Modified Independent; Handles multiple tasks simultaneously in all settings; May need rest breaks

A&O- alert and oriented
For these levels focus on functional abilities

Do not go to rehab until around Ranchos V or VI (need to be medically stable)
Read pgs 109-114


Coma Stimulation

- AKA- Sensory Stimulation

-Involves the use of multi-sensory presentation to medically stable individuals who are comatose or in vegetative states (+)

-GOAL: with intense and repetitive stimulation, the multi-sensory applications will stimulate and “awaken” the reticular formation (responsible for consciousness)


-Western Neuro-Sensory Stimulation Profile (free) LOOK UP

- Train family in what to do and not to do


Coma "Sensory" Stimulation principles

-Coma stimulation is suggested as soon as the Patient is medically stable; range from 1-8h daily to 15-30m sessions

-Collaborate/Educate family; insurance may not cover the cost

-Auditory, Tactile, Proprioceptive, Gustatory, Visual, and Olfactory (part of the sensory stimulation)

Never overstimulate your Patient!

-Overstimulation could cause:
1. flushing/perspiration
2. increased muscle tone
3. agitation
4. prolonged respiration
5. decreased arousal
6. hiccuping/yawning


Cognitive-Communication Impairment

- Communication challenges for the Patient w/TBI are different that those communication challenges observed in a Patient w/CVA

-Cognitive-Communication Impairment: A decreased ability to perform language-based activities because of a deficit in one or more of the cognitive functions that underlie communication (e.g., memory, perception, attention, etc)


Five (5) domains of Cognition: EMAPS

E- executive functioning
M- memory
A- attention
P- problem solving
S- sequencing


Cognition vs. Language

-TBI can cause communication disorders without disrupting language (dysarthria- motor speech disorder)

-TBI can cause language disorders without disrupting communication

-The type of communication deficit depends upon the location and severity of the brain damage

-There is often a mismatch between the surface structure of language (actual words) and the deep surface structure of language (meaning)

-Surface structure- words being used (mismatch between what is said and what the patient means)


Communication Competence

-Need cognition and language
- Communication is a total brain function



- Cognition is intact but Language is impaired.

- Aphasia- Language is affected but cognition is usually intact



- Cognition is affected but language is intact

-Cognition includes:
executive functioning, memory, problem solving, orientation, attention, and social inhibition


Verbal + Gestural Output (TBI)

Patients with TBI may use incorrect words (wrong word choice); exhibit poor sentence structure; paraphasic; neologistic; or perseverate (stay on the same topic, can
change it)
Coprolalia, Copropraxia, Coprographica, and Palilalia



Obscene use of words, swearing, cursing (RLAS IV)



Obscene use of gestures (praxia-movement (bad))



Obscene pictures via draw illustrations



Abnormal speech fluency; Abnormal repetition of syllables, words, phrases w/increasing rapidity and decreasing intelligibility- looks and sounds like cluttering (a form of stuttering)