Disorders of Consciousness 

(DOCS):

Administration and Clinica

Application
Cyber Seminar Speaker

• Theresa Theresa Pape, Dr PH. , MA CCC‐SLP/L

– Clinical Neuroscientist– US Department of Veterans Affairs (Hines VA, 

– Northwestern University Feinberg School of M

Department of PM&R

– Marianjoy Rehabilitation Hospital

• Ann Guernon, MS CCC‐SLP/L, CCRC

– Clinical Research Coordinator– Marianjoy Rehabilitation Hospital and Hines V

HSR&D Cyberseminar, 2011 
Polling Question

• Who is in the audi ? ence

– OT– PT

– Speech Pathologist

– Nurse

– Physiatrist

– Neurologist– Researcher– Administrator– Other

HSR&D Cyberseminar, 2011 
Polling Question

• Do you have experience evaluating pa

states of disordered consciousness?

– Yes– No

HSR&D Cyberseminar, 2011 
What setting setting do you work 

• A t cu e I ti t npatient R h bilit ti Rehabilitation

• Skilled Nursing Facility

• Long Term Acute Care Hospital

• Home Health• Acute Care• Outpatient Clinic• Long Term Care Facility

• VA PRC

• VA PNS

• VA CBOC

• VA Other

• Non‐VA Other

HSR&D Cyberseminar, 2011 
Disclaimer and Conflict o

Interest Statement

• The views expressed in this present ti a on are 

of the authors and do not necessarily reflect 

position or p y olic of the US Department of VeAffairs or the United States government

• The authors including Dr. Theresa Pape nor th

spouses have any fi i l nancial or other rel ti 

a ons

any company who produces products or serv

related to the conduct of the DOCS research

• While specific equipment and material goods 

used in the conduct of the DOCS research, th

do not endorse any specific commerci l a prod

manufacturer

HSR&D Cyberseminar, 2011 
Cyber Seminar Training Training Obje

Obje

A di u ence members will become f ili am ar wi ht :

• The Disorders of Consciousness Scale (DOCS); An 

tool for persons persons with disordered disordered consciousness consciousness

• How to use the DOCS to develop and refine treat

plans according according to an individual individual patient patient s’ level of

neurobehavioral functioning

• How to use the DOCS to inform prognoses for re

consciousness for individual patients

• Current research findings and how to apply that

i f ti n ormation to pl i ann ng pati t en resources, careg

education & adjustment

HSR&D Cyberseminar, 2011 
Intended Clinical Audien

• Any allied health professionals interested in

neurobehavioral evaluation of patients in states 

disordered consciousness.

– Nurses– Speech‐Language Pathologists– Occupational Therapists– Physical Therapists– Neuropsychologists– Physiatrists– Neurologists

HSR&D Cyberseminar, 2011 
Outline

• Characterize Characterize and describe describe severe traumatic traumatic bra

according to impact, consequences and levels disordered consciousness

• Provide an overview of an evaluation tool: The 

of Consciousness Scale (DOCS)

• Outline Goal Setting & Documentation of Prog

• Discuss the current State of the Science

HSR&D Cyberseminar, 2011 
Severe Traumatic Brain Inj 

• Incidence of Severe TBI is About 1% of all TBIs for c

military and Veteran population; Illustrative citation

– US civilian population ≈ 14 per 100,000 new TBIs (E‐M

– Joint Trauma Theater Registry (JTTR), 03 – 07, 604 new 

Severe TBIs ( , DuBose, 2011 J of Trauma)

• Average life span of a person living in a protracted 

disordered consciousness is ≈ 10 years. (Ansell, 19

– JTTR: Mortality Mortality Outcomes Outcomes are better in the military military me

me

relative to civilian data (DuBose, 2011 J of Trauma)

• Persons who suffer a severe TBI continue to make 

improvements in f i unct on for at least 10 years po

(Sbordone, 1995)

• Lifetime Lifetime costs for medical medical care of persons persons living in 

states of disordered states of consciousness rang

$600,000 to $1.8 Million per person. (NIH Consen

Development Panel, 1999)

HSR&D Cyberseminar, 2011 
Consequences of Severe B

Pro

Not 

Laureys, Scientific Awww.comascience

HSR&D Cyberseminar, 2011 
Comatose

• A state of unarousable unarousable neurobehavioral neurobehavioral respons

respons

• No evidence of eye opening either spontaneous 

response to stimulation

• Do not follow commands, demonstrate volitiona

nor verbalize/mouth words

• Pathology: Bilateral hemispheric or Brain Stem (m

and pons) injury

Plum & Posner, Posner, 1980, Diagnosis Diagnosis of Stupor & Co

HSR&D Cyberseminar, 2011 
Vegetative State (VS)

• St t a e of arousal with t ou bh i l e avioral ev

of awareness of self or capacity to inte

with the environment

• Wakefulness (spontaneous or stimulu

induced) is preserved

• Pathology: Common feature is diffuse 

to white matter of the cerebral cerebral hemis

hemis

and/or thalamus

Adams, 2000 Brain 123: 1327‐38

Jennett, 1972 Lancet 1:734‐37.

HSR&D Cyberseminar, 2011 
Minimally Conscious State (

• A condition in which minimal but definite behav

evidence of self or environmental awareness isdemonstrated

• Inconsistent occurrence of :

– Following simple commands

– Gestural or verbal “yes/no” response

– Intelligible verbalizations

– M t ovement or aff ti ec ve bh i e av ors th t a occur i

to relevant environmental stimuli and not ref

• Giacino J. Neurology. 2002;58(3):349‐353

• P hl at o ogy: B i e ng i id nvestigated

Schiff, 2005, 64 (3) 514‐523

HSR&D Cyberseminar, 2011 
HSR&D Cyberseminar, 2011 
Recovery of Full Consciousn

(Emerge from MCS)

• Pape Lab Research Definition:

– Reliable Reliable and consistent consistent demonstration demonstration o

the following:

• Functional interactive communication• Functional use of one or more objects• Behavioral manifestation of a sense of self in 

environment

– Examples

– Hi hg er l l eve C iti ogn ve T ti es ng I di t d ndicated

Pape, T HSR&D Cyberseminar, 2011 
Polling Question

• Have you administered the Disorders 

Consciousness Scale?

– Yes– No

HSR&D Cyberseminar, 2011 
Polling Question

• What other neurobehavioral scales fo

p po ulation do you use?

Open end de

HSR&D Cyberseminar, 2011 
What should Clinicians get fr

Neurobeahvioral Evaluation fo

populi ? at on

• Capacity to monitor recovery using repeated measures over a

period of time:

– Detects subtle changes in neurobehavioral functioning

– Reliability, validity and precision over time

• Capacity to determine determine intervention intervention effects: effects:

– Detect a short term effect using single subject designs in daily cl

– Clinical Trials

– Reliability, Reliability, validity validity and precision precision over time

• Evidence to:

– Inform clinical decisions during and after acute rehabilitation– Share with families families and caregivers caregivers– Inform short and long term prognoses of meaningful outcomes

• Meaningful to who?

• Diagnosis if it will influence treatment plans and prognoses

HSR&D Cyberseminar, 2011 
Polling Question

• What decisions are you making on be

persons living in states of disorderedconsciousness?

– Open ended

HSR&D Cyberseminar, 2011 
Polling Question

• What evidence/information would inf

guide these decisions?

– Open ended

HSR&D Cyberseminar, 2011 
Disorders of Consciousness S

(DOCS)

• First Step: Develop the DOCS to detect s

changes in ob bl servable indicators of

neurobehavioral functioning to:

– Measure Neurobehavioral Functioning with 

capacity to know the precision/accuracy of 

measure

– Measure Changes in Neurobehavioral Funct

descriptor descriptor of recovery recovery as well as in response response 

interventions

– Predict short and long term outcomes

HSR&D Cyberseminar, 2011 
DOCS Reliability & Validity: 20

2004

Given a 2 hour training (Interactive l 

ecture

Practice session:

• Inter‐rater reliability reliability between between disciplines disciplines 

level of agreement

• Rat g in Sca el : Fu ct o g nctioning as t eo ed h rized

• Rater reliability = .93 (2011 final report)

• No rater bias over time ( y weekl for 6 we

• No item bias over time (weekly for 6 wee

• Rater severity & leniency by discipline do

bias DOCS measures

Source: Pape T et al Journal of Reh

HSR&D Cyberseminar, 2011 

Source: Pape T, et al. Journal of Reh

Research and Development. 2005;41
DOCS Validity: 2004 ‐ 200

• Construct Validity: 23 of 34 test stimuli r

st bl a e over time with no floor or ceiling 

• Targeting of Items to Population• Dimensionality• Preliminary Predictive Validity (73% ‐ 77

accuracy using baseline baseline DOCS)

Source: Pape T, et al. Journal of Rehabilitation 

Research and Development. 2005;41:1-18

• Predictive Validity: DOCS measures obta

within 94 days of injury predicted recove

i t 1 ft i j 

p ; 8

consciousness up to 1 year after injury w

to 91% accuracy (using DOCS change)

Source: Pape T et al Physical Medicine &

HSR&D Cyberseminar, 2011 

Pape T et. al. Physical Medicine &

Rehabilitation, 2009; 1:2, 152-161
Recently completed Research: 

2011

• C fi t on rmatory psych ti ome r c st du y

– Update will be out in 2012

• Rater Severity Severity & Leniency Leniency

– 2012

• MCID

– 2013

• Diagnostic Validity• Predictive Validity

– Consciousness (2012)– Function

• Expression of Needs Under Review• Other functions: functions: Pape et al 2006 Brain Injury

HSR&D Cyberseminar, 2011 
DOCS

• Baseline Observation Protocol• 23 Test Stimuli/Items• 3 Point Rating Scale

• 0 = No Response; Response; Response Response does not differ f

baseline behavior

• 1 = General Response

• 2 = Localized Response; Response IS context

related to the test stimuli

• Elicit and Score Best Responses

– Best response profile

HSR&D Cyberseminar, 2011 
23 Test Stimuli

• Social Knowledge

Greet

• Auditory

– Whistle

• Taste and Swallowing

– Juice

Massage

– Whistle– Clap– Name

– Massage – Bell

• Olfactory

– Odor

• Proprioceptive/Vestibular

– Bell– Command

• Visual

– Blink • Proprioceptive/Vestibular

– Joint

• Tactile

Ai

– Blink– Focus– Tracking Objects– Tracking Familiar F

– Air

– Feather– Hair

Toe

Tracking Familiar F

– Focus Familiar Fac

– Toe– Hand (Arm Massage)– Scrub– Swab– Cube

HSR&D Cyberseminar, 2011 
HSR&D Cyberseminar, 2011 
No Response

• No active movement or vocalization fo

the presentation of the stimuli

• Response to sti li mu does not differ fro

behavior observed during baseline

observation

HSR&D Cyberseminar, 2011 
Generalized Responses

• A general response is NOT pred bl icta e

• Is not contextually related to test stim

is different from baseline behavior

• Form B contains contains several several examples examples, bu

NOT be considered:

– An all inclusive inclusive list– A “recipe”– Always use your cli i l n ca j du gment

HSR&D Cyberseminar, 2011 
Examples of

Generalized Responses (G

• If different from baseline, then the fol

cou dl be e a p es examples of Ge e a ed Generalized Res

es

– Reflexes differing from reflexes observed 

baseline

– Changes in respiration– Changes in Tone (Increase/Decrease) (Increase/Decrease)– Muscle tensing or other movements unr

the area stimulated

HSR&D Cyberseminar, 2011 
GR Examples (cont ) (cont...)

• If different from baseline, then these 

also be examples of GR:

– Unrelated vocalizations– Blinking Blinking that deviates deviates from baseline baseline– Deviation in blood oxygen levels from ba

range

– Deviation in heart rate from baseline ran

– Eye opening

HSR&D Cyberseminar, 2011 
Localized Responses

• A response, not observed at baseline, 

contextually related to the test stimul

• The response reflects an ability of the 

to regulate regulate incoming incoming sensory sensory informat

informat

is constantly changing, and to control 

motoric responses to the sensory inpu

HSR&D Cyberseminar, 2011 
Examples of Localized Localized Respo

Respo

• If different from baseline, then the fol

could be examples examples of Localized Localized Respo

Respo

– Orienting or localization movements tow

sound

– Vocalization or response indicating subje

comprehension of a greeting

HSR&D Cyberseminar, 2011 
Generalized versus Localiz

• If the diff i i erentiation between a GR and a LR 

unclear, then follow this guideline:

– A l li d ocalized, response is a response th t a is cont 

e

related to the stimulus provided

– The production production of a localized localized response response requires requires 

regulation of incoming stimulation and an abilit

voluntarily control the response to the stimulat

– Localized responses occur in relationship to the 

stimulated and these responses are not attribu

reflexic activity

HSR&D Cyberseminar, 2011 
Summary of Rating Scal

• No Response = 0

– No active movement or vocalization in respons

OR no change in response from baseline

• Generalized Response = 1

– Response is not contextually related to test stim

different from baseline behavior

• Localized Response = 2

– Response, not observed at baseline, that is con

related to test stimuli

HSR&D Cyberseminar, 2011 
Optimal Testing Environmen

Environment that elicits best res

• Post “Do Not Disturb” sign

• Close the door

• Eliminate unpredictable noises (e.g., TV, radio

intercom, phone)

• Diminish bright lights (e.g., close or partially 

blinds if sunlight is exceptionally bright)

• Avoid inadvertent tactile & auditory stimulat

• Rule out visual impairments for Testing Read

• Re‐position throughout the test as needed

– See positioning procedures & guidelines in DOC

HSR&D Cyberseminar, 2011 
Baseline Observations

• A bh l e avioral b l ase ine against wh hic

subsequent change can be measured

• Determines the level of neurobehavio

functioning associated with each resp

the test stimuli

• Critical to accurate accurate measurement measurement

• Double check the testing environment 

compl ti e ng the B li ase ne Ob ti servation

HSR&D Cyberseminar, 2011 
Evaluation Session

• 23 Test Stimuli

– 40‐60 minutes– Two 20‐30 minute sessions

• 24 hours• Baseline observations are completed each t

HSR&D Cyberseminar, 2011 
Administration and Scori

General Guidelines

• 23 Test Stimuli (other items are research ite

• Scoring Forms

B

= Long Form

A

= Short Form

• Apply each stimulus for

5 seconds

• Observe Observe for 10

‐15 seconds seconds after administer

administer

stimuli and wait 30

‐60 seconds prior to adm

the next test stimulus stimulus

HSR&D Cyberseminar, 2011 
Administration and Scori

Guidelines (cont...)

•

T

h

e num

ber

o

f times eac

h stimulus is

administered/repeated is determined 

clinical judgment

• Alwa

y

s score the best res

ponse. If

a

2 

scored, then repeat administrations o

side of bod

y ( y) bilaterally)

• Specific directions for test administrat

each item is provided provided in the DOCS Tra

Tra

Manual and DVD

HSR&D Cyberseminar, 2011 
Whi tl s e: Bl hi tl h l d Blow whistle sharply and

loudly one time behind ear

Clap: Clap hands sharply and loudly 

one time behind ear

Name: Call out patient’s name 

(first name last name or (first name, last name, or

nickname); if repeating this stimuli 

then be sure to vary the inflection then be sure to vary the inflection

and loudness with each repetition 

HSR&D Cyberseminar, 2011 
Focus Object: Hold 3-dimenstional object in a 

approxi t l 18 i h f f imately 18 inches from face

Track Object: Present object in the left visual f

move object right cross midline (horizontal)move object right, cross midline (horizontal)

2 is not given, then repeat moving right to le

◦ If a score of 2 is still not given then test vertical trac

presenting object in middle visual field slowly move presenting object in middle visual field, slowly move 

upward

◦ You can start with vertical and end with horizontal

HSR&D Cyberseminar, 2011 
` Converting Total Raw Scores to Total 

Measures

` Inte p etat o o OCS easu es rpretation of DOCS Measures` Converting y DOCS Modality Raw Score

Modality Measures.

` Interpretation of Modality Measures

HSR&D Cyberseminar, 2011 
HSR&D Cyberseminar, 2011 
` Refer to Conversion Tables in Trainin

Manual

` Calculation of Raw Score

◦ Add scores of 23 items◦ What if items are skipped?

` Conversion of Raw Score to DOCunit

◦ Closed Head Injury vs. Other Brain Injury

` What does this mean?

HSR&D Cyberseminar, 2011 
Conversion Table for Closed Head Injuries

DOCS Raw 

Score

DOCunit Standard

Error

Percentile

21 48.6 2.7 22 49.3 2.7 23 50.0 2.7 

Score Error

0 5.0 18.2 11 16..8 9.9 12 23..5 6.9 3

24 50.7 2.7 25 51.4 2.7 26 52.2 2.7 27 52.9 2.7 

3 27.4 5.7 44 30..2 4.9 65 32.4 4.4 7

28 53.7 2.7 29 54.4 2.8 30 55.2 2.8 

6 34.1 4.1 9

7 35.7 3.8 128 37.0 3.6 13

31 56.0 2.9 32 56.8 2.9 33 57.7 3.0 34 58.6 3.1 

→

9 38.3 3.4 15

10 39.4 3.3 1611 40.4 3.2 19

12 41 4 3 1 21

35 59.6 3.2 36 60.6 3.3 37 61.8 3.4 

12 41.4 3.1 2113 42.3 3.0 2214 43.2 2.9 2515 44.0 2.9 28

38 63.0 3.6 39 64.3 3.8 40 65.9 4.1 41 67.6 4.4 

16 44.8 2.8 3017 45.6 2.8 3318 46.3 2.7 3719 47 1 2 7 41

42 69.8 4.9 43 72.6 5.7 44 76.5 6.9 

19 47.1 2.7 4120 47.8 2.7 43

45 83.1 9.9 46 95.0 18.2 

HSR&D Cyberseminar, 2011 
` Monitoring Recovery Over Time

` Modality Measure Conversion` Interpretation and Application of Mod

Measure Information Measure Information

HSR&D Cyberseminar, 2011 
Average DOCS Measures Every 2 Wee

(N 91 P & 141 DOCS) (N = 91

Persons 

& 141 DOCS)

7080 Total Sample CHI/MVA CHI/MV5060

OCUnits

3040

D

20

0-14

15-28

29-42

43-56

57-70

71-84

85-98

99-112

113-126

127-140

141-154

155-168

169-182

183-196

19

1

1

1

1

1

1

Days after Injury

HSR&D Cyberseminar, 2011 
` DOCS Modality Scoring Tables

` Modality Specific Conversion Chart

HSR&D Cyberseminar, 2011 
Conversion Table for Ta

Tactile DOCunit Score 

Tactile Item #

DOCS Tactile Test Item

Best Raw Score 1st

Evaluation

Best Raw Score 2ndEvaluation Tactile

Modality 

Raw Score

DOCunit Score

for Tactile Items

0 12.2 1 24 2 

T1 1. AIR 2T2 2. FEATHER 1 1 24.2 

2 31.2 3 35.5 4 38.7 

T3 3. HAIR 0T4 4 TOE (Vibration) 2 5 41.4 

6 43.7 7 45.9 

T4 4. TOE (Vibration) 2T5 5. HAND (Massage) 0

8 48.0 9 50.0 

10 52.0 

T6 6. SCRUB 1T7 7. SWAB 1

11 54.1 12 56.3 13 58.6 

T8 8. CUBE 2PV1 9 JOINT 14 61.3 

15 64.6 16 68.9 

9. JOINT 1

TOTAL RAW TACTILE SCORE 10

17 75.9 18 87.8 

DOCS Tactile Score (Obtained from modality conversion chart) 52.0

HSR&D Cyberseminar, 2011 
DOCS Results For One Subject By Modali

905070

Cunits

10

DO30

85-98

113-126

141-154

169-182

197-287

301-307

312-321

329-336

344-350

358-364

Days After Injury

Auditory DOCS Tactile DOCSVisual DOCS Total DOCS

HSR&D Cyberseminar, 2011 
` Objectively document progress by mo

Objectively document progress by mo

` Develop interdisciplinary and uniform 

communication system communication system

` Identify strengths and weaknesses by 

modality

` Diagnosis of sensory deficits (i.e. blin

deaf)

HSR&D Cyberseminar, 2011 
90

7080

res

5060

Measur

3040

OCS M

10

D20 

0

Date of DOCS Evaluation

HSR&D Cyberseminar, 2011 
Predicting Time to Consciou

Consciou

• Goal: Predict Recovery and Lack of Recovery 

Consciousness at multiple time points within 

first year of injury with

– Equal accuracy (Balanced Predictions)

• Sensitivity (Se) = Predict recovery of

consciousness when consciousness consciousness really dooccur

• Specificity Specificity (Sp) = Predict Predict lack of recovery recovery of

consciousness when it really does not occur

HSR&D Cyberseminar, 2011 
Time to Consciousness Most Ba

Predictions

DOCS B li d DOCS Ch TBI ( DOCS Baseline and DOCS Change: TBI (n 

4 Months 8 Months 1

AUC Se Sp AUC Se Sp AU

Baseline DOCS 

< or > 48

.82 .78 .76 .83 .80 .80 .73 

DOCS Change 

1st - 5th

.87 .86 .83 .81 .75 .75 .88 

DOCS Change DOCS Change 91 84 87 88 83 83 80 

1st - 2nd

.91 .84 .87 .88 .83 .83 .80 

Source: Pape TL-B, Tang C, Guernon A et al. th Di d f C i S l (DOCS) 

HSR&D Cyberseminar, 2011 

the Disorders of Consciousness Scale (DOCS). 

and Rehabilitation. 2009.
Interpreting sensitivity a

specificity: Example

• Example: DOCS Change measured from 1st

and 5th DOCS when predicting recovery ofconsciousness 4 months after injury

– This measure of change predicted recovery wh

act ll ua y occurred 86% (S iti it ) ensitivity) of the time a

when it actually did not occur 83% (Specificity) 

the time

– Yielding a False Negative rate of 14% and a Fals

Positive rate of 17%.

– Each prediction will be accurate 88% of the tim

HSR&D Cyberseminar, 2011 
Time to Consciousness: Consciousness: Influe

Influe

Magnitude of Change

HSR&D Cyberseminar, 2011 
Timeframe for 7 to 9 units of 

Change

• Baseline acqui d re wi hi t n 94 days of i j n ur

• Average # of days during which 7, 8 and 

of DOCS change occurred

– Ranges from 18 to 22 days– Evidence indicates that DOCS evaluations ca

conducted every other week

– While evidence suggest that repeat DOCS e

do not have to be conducted every 7 days to

sufficiently sufficiently capture/detect capture/detect this amount of c

suggest a conservative repeat testing sched

every 7 to 10 days.

HSR&D Cyberseminar, 2011 
Predicting Predicting Recovery Recovery of Functional Functional S

Year after Injury

HSR&D Cyberseminar, 2011 

Source: Pape T, Lundgren S, Heinemann A et al. Establishi

Functional Outcome during Coma Recovery, Brain Injury. 20
Prognostic Information Base

Modality Specific Informat

• Recovery of Functional Skills 1‐Year af

Injury

• Additional Independent Variables

– DOCS A dit u ory Measure

– DOCS Tactile Measure

– DOCS Visual Measure

HSR&D Cyberseminar, 2011 
Dependent 

Significa

Predict

Models Variables Variabl

Tactile Average + pneum + HTN+ seiz + UTI

Time out of Bed UTI

Visual Average + pneum + seiz+ UTI

Cognitive Assistance Seizur

Visual Average + pneum + seiz Visual Average + pneum + seiz Recovery of Visual Ave

+ UTI

Recovery of

Consciousness

Visual Ave

Auditory Average + pneum + Recovery of Audito

seiz + UTI + HTN Consciousness Averag

Auditory Average + pneum + 

seiz + UTI + HTN

Communication 

Assistance

Audito

seiz + UTI + HTN Assistance Averag

Averag

Auditory Average + pneum + seiz + UTI + HTN

Cognitive Assistance Audito

Averag

Auditory Average + pneum + seiz + UTI + HTN

Social Contact Audito

Averag

HSR&D Cyberseminar, 2011 

Source: Guernon A, Roth H et al. 2008. HSR&D Cyberseminar, 2011 
Polling Question

• When you see patients in d dd isor ered s

consciousness what is the most comm

etiology?

– Blunt Trauma– Blast Trauma– Other Trauma– Anoxia– Stroke– Other

HSR&D Cyberseminar, 2011 
Future Research

• AS we learn more about this population population, the

always be updates and some things to watch 

– Short Form– Diagnostic‐MCID

– Prognostication

– Rater severity/leniency calibration system

– Relationship of DOCS auditory scores with BAER 

– Clinical states of disordered consciousness– Empirically derived states of altered consciousn– Reconcile clinical and empirical evidence

• Diagnostic algorithm

HSR&D Cyberseminar, 2011 
Summary: Clinical Implemen

of fi di n ngs

• Monitoring: Currently being implemented

– Bi‐weekly is recommended if using DOCS to detect chan

• Current Applications of DOCS Test Results

– Rehabilitation Goal Setting,– Dt ii e ermining Sh t or Term T t t/I t ti Treatment/Intervention Eff t ec s

• Evidence Based Prognoses after Severe TBI for

Individual Patients is Possible: Possible:

– Recovery of Consciousness: Ready for Clinical Implemen

• Accuracy (Error) associated with each prediction/probability• Definition of consciousness

– Functional skill recovery: Not ready for clinical

implementation

HSR&D Cyberseminar, 2011 
Summary: Research Impleme

Currently in use for:

• Cli i l Clinical ti l r a s as primary tt t rea ment a

rehabilitation effect/outcome

• Observational research• Investigations of mechanisms mechanisms of

neurobehavioral recovery

HSR&D Cyberseminar, 2011 
Polling Question

• What other clinical topics related to d

of consciousness would you be intere

• Open end de

HSR&D Cyberseminar, 2011 
Polling Question

• What other research topics regarding 

disordered consciousness would you b

interested in?

– Open ended

HSR&D Cyberseminar, 2011 
Interested in Administering the 

at your facility?

Order DOCS Training DVD & Manu

Contact Cheryl Odle at:

Cheryl.odle@va.gov

HSR&D Cyberseminar, 2011 
Acknowledgements

• US Department of Veterans Affairs, Office of Resea

Development

– Health Services Research & Development (CCN07‐133‐1)

– Rehabilitation Research & Development (B2632‐V, B3302

• Therapists Therapists and Clinicians Clinicians at Participating Participating Hospitals: Hospitals:

– Minneapolis VAMC– Northwestern Memorial Hospital– The Rehabilitation Institute of Chicago

– RML Specialty Hospital

– Marianjoy Rehabilitation Hospital

– Tampa VAMC

– On With Life, Brain Injury Rehabilitation

– Northwestern University’s Feinberg School of Medicine– Edward Hines Jr. VA Hospital

• Nick Kot Charity (www.nkc4tbi.com)• The pati t en s and th i e r f ili /l d amilies/loved ones

HSR&D Cyberseminar, 2011
Contact Info

• Theresa Pape, Dr. PH, MA CCC‐SLP/L

– Neuroscientist, Hines VA– Theresa.pape@va.gov

• Ann Guernon, MS CCC‐SLP/L

– Clinical Research Coordinator, Marianjoy Rehab

Hospital

– aguernon@marianjoy.org or ann.guernon@va.

• Cheryl Odle, MBA

– Project Manager, Hines VA– cheryl.odle@va.gov

HSR&D Cyberseminar, 2011 
Cited References

1. Gi i ac no J, Ah l s wa S, Childs N, et al. The mi i ll n ma y conscious s

and diagnostic criteria. Neurology. 2002;58(3):349‐353.

2. Jennett B & Plum F. Persistent vegetative state after brain inj

in search of a name. L t ance . 1972 1(7753) 734 1972;1(7753):734‐737.

3. Ansell BJ & Keenan JE. The Western Neuro Sensory Stimulat

for assessing slow‐to‐recover‐head‐injured‐patients. Archive

Medicine & Rehabilitation Rehabilitation. 1989 70 104 1989;70:104‐108.

4. NIH Consensus Development Panel on Rehabilitation of Perso

Traumatic Brain Injury. JAMA. 1999;282:974‐983.

5. Sb d or one RJ, Liter JC & Pettler‐Jennings P. Recovery of f 

unct 

severe traumatic brain injury: a retrospective 10‐year follow

1995;9(3):285‐99.

6. Laureys S. Eyes open, b i ra n sh t u . S i tifi Scientific A i mer can. 2007; 2

7. Plum F & Posner J. The Diagnosis of Stupor and Coma, 3ed. 1

Philadelphia,PA: FA Davis Co.

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