Ontario Neurotrauma Foundation

Clinical Practice Guideline

For the rehabilitation of Adults with Moderate to Severe TBI

Ontario Neurotrauma Foundation INESSS
SECTION 2: Assessment and Rehabilitation of Brain Injury Sequelae > I. Disorders of Consciousness

I. Disorders of Consciousness

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Research suggests that the responsiveness and environmental awareness of people in vegetative state (VS) or minimally conscious state (MCS) is often underestimated by clinicians.  The mainstay of diagnosis is clinical evaluation for evidence of localizing or discriminating behaviours indicating awareness of self or the environment. The Glasgow Coma Scale (GCS) is widely used in acute settings to evaluate the level of consciousness. Clinicians must be aware that although the GCS is very useful for some aspects of traumatic brain injury (TBI) care, it is not a valid diagnostic tool for prolonged disorders of consciousness (PDOC), and more sensitive and refined assessment is required to categorize prolonged disorders of consciousness (PDOC).  This is important as treatment and prognosis is highly dependent on accurate differentiation of the type of disorders of consciousness (DOC). Families can frequently play an important role.

For patients who are in a state of post-traumatic amnesia (PTA), it is necessary to document their progression to identify patterns of recovery and also to plan for when patients may be ready to progress to active sub-acute rehabilitation. Formal evaluation with validated tools is necessary given the fluctuating course of recovery associated with poor awareness typical at this level of recovery. Further, clinical care should focus on an orienting, structured, less stimulating environment with efforts focussed on minimizing use of restraints and sedating medications.

The team may need to do prolonged observations and multiple trials to determine true responsiveness of those in prolonged VS.  The use of a tilt table or other mechanical device will likely be required and should be available in any centre that cares for patients with low levels of consciousness (LCFS 1-2).  For patients with LCFS scores of 3 to 5 who are in a PTA state, the care environment must be able to provide a low stimulation environment with structure and consistency of care including consistent staffing as well as orienting information and materials for patients.


Indicators exemples

  • Number and proportion of patients with whom restraints are used.

  • Frequency of the use of restraints / week.

  • Average duration of the use of restraints.

  • Presence of low stimulation rooms (LSR).

  • Average length of LSR use (days).

The following are suggestions of tools and resources that can be used to support the implementation of the recommendations in this section. Healthcare professionals must respect the legal and normative regulations of the regulatory bodies, in particular with regards to scopes of practice and restricted/protected activities, as these may differ provincially

Clinical Tools:

Patient and Family Resources:

Other Resources:

All individuals with TBI, who have a disorder of consciousness, require close and ongoing, assessment and observation.  Family members may play a productive role in the early stages of care, especially with regaining consciousness.   Abbasi et al. (2009) conducted a RCT to evaluate the effect of sensory stimulation through structured family visits on consciousness as assessed by the GCS. Families received training on coma; how to provide appropriate stimulation and how to remain calm.  Patients receiving family visits showed significantly greater GCS scores on each day of the intervention and attained a mean GCS that was 2 points higher than that of the control group. Although no long-term outcomes were evaluated and no follow-up was reported, these results suggest that family provided stimulation is beneficial (Abbasi et al., 2009).

PTA duration is often used as an indicator of injury severity and as a predictor of outcome; therefore, it has been recommended that a validated PTA assessment tool be performed regularly until PTA has resolved (J. Ponsford & Sinclair, 2014). Numerous studies have examined potential assessment tools (Frey, Rojas, Anderson, & Arciniegas, 2007; Jackson, Novack, & Dowler, 1998; Shores, 1995; Tate et al., 2006; Tate, Pfaff, & Jurjevic, 2000). Recommendations regarding the management of individuals with PTA have been made mainly on clinical experience and little research is available to support these guidelines (Ponsford & Sinclair, 2014; Ponsford, Tweedly, Lee, & Taffe, 2012; Snow & Ponsford, 2012). 

Abbasi, M., Mohammadi, E., & Sheaykh Rezayi, A. (2009). Effect of a regular family visiting program as an affective, auditory, and tactile stimulation on the consciousness level of comatose patients with a head injury. Jpn J Nurs Sci, 6(1), 21-26.

Frey, K. L., Rojas, D. C., Anderson, C. A., & Arciniegas, D. B. (2007). Comparison of the O-Log and GOAT as measures of posttraumatic amnesia. Brain Inj, 21(5), 513-520.

Jackson, W. T., Novack, T. A., & Dowler, R. N. (1998). Effective serial measurement of cognitive orientation in rehabilitation: the Orientation Log. Arch Phys Med Rehabil, 79(6), 718-720.

Ponsford, J., & Sinclair, K. (2014). Sleep and fatigue following traumatic brain injury. Psychiatr Clin North Am, 37(1), 77-89.

Ponsford, J., Tweedly, L., Lee, N., & Taffe, J. (2012). Who responds better? Factors influencing a positive response to brief alcohol interventions for individuals with traumatic brain injury. J Head Trauma Rehabil, 27(5), 342-348.

Shores, E. A. (1995). Further concurrent validity data on the Westmead PTA Scale. Appl Neuropsychol, 2(3-4), 167-169.

Snow, P., & Ponsford, J. (2012). Assessing and managing impairment of consciousness following TBI (2nd ed.). London, UK: Psychology Press.

Tate, R. L., Pfaff, A., Baguley, I. J., Marosszeky, J. E., Gurka, J. A., Hodgkinson, A. E., . . . Hanna, J. (2006). A multicentre, randomised trial examining the effect of test procedures measuring emergence from post-traumatic amnesia. J Neurol Neurosurg Psychiatry, 77(7), 841-849.

Tate, R. L., Pfaff, A., & Jurjevic, L. (2000). Resolution of disorientation and amnesia during post-traumatic amnesia. J Neurol Neurosurg Psychiatry, 68(2), 178-185.



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P Priority F Fundamental New Level of evidence A B C

I 1.1 C

All individuals with traumatic brain injury who have a disorder of consciousness require regular medical and neurological assessments and serial monitoring.

(Adapted from NZGG 2006, 2.2.4, p. 39)

I 1.2 P C

Immediate medical and physical re-evaluation should be conducted when a fall or unexpected change in the Glasgow Coma Scale (GCS) score of more than 2 points (or a fall in another appropriate metric reflecting neurological status, e.g. CRS-R) is observed in a person with disorders of consciousness.

(Adapted from NZGG 2006, 2.2.1, p. 37)

Note: Deterioration in the GCS scores or failure to improve as expected with time post-injury should trigger immediate re-evaluation of the clinical situation with investigation urgency and/or urgent referral commensurate with the clinical situation.

I 1.3 C

Diagnosis of vegetative state (VS) or minimally conscious state (MCS) following traumatic brain injury should be based on assessment:

  • By appropriately trained clinicians who are experienced in VS or MCS :

    - Under suitable conditions

    - Using validated structured assessment tools

    - In a series of observations over an adequate period of time

  • In conjunction with clinical reports of behavioural responses gleaned from:

    - The care records

    - Interviews with family members / healthcare professionals

(RCP 2013, Section 2; 2.3, p. 33)

I 1.4 B

Clinicians should work closely with the family members of the person with traumatic brain injury with prolonged disorders of consciousness (PDOC), explaining what behaviours to look for and how to distinguish higher-level responses from reflex activity. Where appropriate, families may also be encouraged to use tools or videos to record their observations.

(Adapted from RCP 2013, Section 2; 2.4, p. 33)

Note: Families play an active role in the assessment of individuals with PDOC because individuals may respond at an earlier stage to their families / loved ones.

P Priority F Fundamental New Level of evidence A B C

I 2.1 C

Post-traumatic amnesia (PTA) assessment of a person with traumatic brain injury should be performed on a serial basis using a validated tool, until resolution of the PTA.

(Adapted from NZGG 2006, 2.2.3, p. 38, INCOG 2014, Assess 2; PTA 1, p.296 and INCOG 2014, PTA 1, p. 314)

I 2.2 P C

To minimize agitation and confusion associated with post-traumatic amnesia (PTA), individuals with traumatic brain injury (TBI) should remain in a secure and supervised environment until they have emerged from PTA.

It is recommended to:

  • Maintain a quiet and consistent environment on the ward and avoid overstimulation

  • Consider the use of low-stimulation rooms

  • Evaluate the impact of visitors, assessment and therapy and limit these activities if they cause agitation or excessive fatigue, allowing rest as needed

  • Minimize the use of restraints while facilitating the use of alternate measures in order to allow the person to move around freely

  • Have consistent healthcare professionals or trained caregivers working with the person with TBI

  • Establish the most reliable means of communication

  • Provide frequent reassurance

  • Present familiarizing information as tolerated by the person

  • Help family members understand PTA and how to minimize triggering agitation

(Adapted from INCOG 2014, PTA 3, p. 314)

Suggested tool: Algorithm for Agitation and Agression

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