title: Detailed behavioral assessment promotes accurate diagnosis in patients with disorders of consciousness.
abstract: BACKGROUND
  Assessing the awareness level in patients with disorders of consciousness (DOC) is made on the basis of exhibited behaviors. However, since motor signs of awareness (i.e., non-reflex motor responses) can be very subtle, differentiating the vegetative from minimally conscious states (which is in itself not clear-cut) is often challenging. Even the careful clinician relying on standardized scales may arrive at a wrong diagnosis.
  
  
  OBJECTIVE
  To report our experience in tackling this problem by using two in-house use assessment procedures developed at Reuth Rehabilitation Hospital, and demonstrate their clinical significance by reviewing two cases.
  
  
  METHODS
  (1) Reuth DOC Response Assessment (RDOC-RA) -administered in addition to the standardized tools, and emphasizes the importance of assessing a wide range of motor responses. In our experience, in some patients the only evidence for awareness may be a private specific movement that is not assessed by standard assessment tools. (2) Reuth DOC Periodic Intervention Model (RDOC-PIM) - current literature regarding assessment and diagnosis in DOC refers mostly to the acute phase of up to 1 year post injury. However, we have found major changes in responsiveness occurring 1 year or more post-injury in many patients. Therefore, we conduct periodic assessments at predetermined times points to ensure patients are not misdiagnosed or neurological changes overlooked.
  
  
  RESULTS
  In the first case the RDOC-RA promoted a more accurate diagnosis than that based on standardized scales alone. The second case shows how the RDOC-PIM allowed us to recognize late recovery and promoted reinstatement of treatment with good results.
  
  
  CONCLUSIONS
  Adding a detailed periodic assessment of DOC patients to existing scales can yield critical information, promoting better diagnosis, treatment, and clinical outcomes. We discuss the implications of this observation for the future development and validation of assessment tools in DOC patients.
authors: Department of Occupational Therapy, Reuth Rehabilitation Hospital Tel Aviv, Israel ; Brain Injury Division, Reuth Rehabilitation Hospital Tel Aviv, Israel.
authors: Yael
authors: Y
authors: Gilutz
authors: Brain Injury Division, Reuth Rehabilitation Hospital Tel Aviv, Israel.
authors: Avraham
authors: A
authors: Lazary
authors: Department of Occupational Therapy, Reuth Rehabilitation Hospital Tel Aviv, Israel.
authors: Hana
authors: H
authors: Karpin
authors: Outpatient and Research Division, Reuth Rehabilitation Hospital Tel Aviv, Israel ; Sackler School of Medicine, Tel Aviv University Tel Aviv Israel.
authors: Jean-Jacques
authors: JJ
authors: Vatine
authors: Department of Occupational Therapy, Reuth Rehabilitation Hospital Tel Aviv, Israel ; Brain Injury Division, Reuth Rehabilitation Hospital Tel Aviv, Israel.
authors: Tamar
authors: T
authors: Misha
authors: Department of Occupational Therapy, Reuth Rehabilitation Hospital Tel Aviv, Israel.
authors: Hadassah
authors: H
authors: Fortinsky
authors: Sackler School of Medicine, Tel Aviv University Tel Aviv Israel ; Institute of Pain Medicine, Tel Aviv Sourasky Medical Center Tel Aviv, Israel ; Center for Brain Functions, Tel Aviv Sourasky Medical Center Tel Aviv, Israel.
authors: Haggai
authors: H
authors: Sharon
keywords: behavioral assessments; brain injury; disorders of consciousness; minimally conscious state; vegetative state