Birdi J, Myers R, Stern C, Martin R, Whyte J; Moss Rehabilitation Hospital, Philadelphia, PA. jasleenb@hotmail.com.

PURPOSE: The purpose of this case report is to present 2 protocols, based on a single-subject experimental design, that were implemented to establish a communication system for a patient admitted into MossRehab's Responsiveness Program (MRRP). FOUNDATION: After severe brain injury, it is difficult to determine a patient in a vegetative state from a minimally conscious state, in which "minimal but definite behavioral evidence of self or environmental awareness is demonstrated"). These protocols are one way to determine the presence of these overlooked behaviors to better guide our treatments as clinicians. DESCRIPTION: A 33 year-old male presented to the emergency room secondary to an assault with a baseball bat; Glasgow Coma Scale was 7 on admission. A CAT scan revealed a right parietal sub-arachnoid hemorrhage, falcine sub-dural hematoma and a left basilar fracture. Upon admission to MRRP, the patient was not visually tracking. A visual protocol was initiated with the use of a color photo and a plain white card. Six trials of the visual stimuli were presented in the patient's visual field in a random order. The purpose of this protocol was to assess visual function and attention in both fields, based on the patient's orienting eye movements to the stimuli. Another protocol was established to assess this patient's ability to communicate through yes/no head movements while biographical questions were presented. The protocols were executed during each therapy session for approximately one month. An on/off trial of Ritalin was administered during the second protocol. All team members, except for the nursing staff, were blinded to the drug trial. OBSERVATIONS: The findings of the visual protocol demonstrated presence of vision in both fields with a mild right inattention. The findings of the yes/no protocol, when the effects of the drug were not considered, showed an increase in response rate(RR) from 48% to 89% and an increase in accuracy rate(ACC) from 75% to 85%. Trials while the patient was on Ritalin showed a RR of 92% and ACC of 83%; off Ritalin, the RR was 97% and ACC was 90%. CONCLUSIONS: The data indicated this patient was in a minimally conscious state and not vegetative, which is differentiated by the presence of purposeful behavior and gestural yes/no responses. Determining the presence of visual function and attentional deficits helped the therapists guide their interventions. Ritalin was discontinued because the increased RR and ACC off Ritalin were ascribed to spontaneous recovery. FUNDING SOURCE: None.

Copyright 2004 by the American Physical Therapy Association

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