Treatment & Intervention > Treatment Ideas: DoC
OT Treatment Ideas: Disorders of Consciousness
Before starting, position the patient for success. A patient slumped with an arm pinned against the side rail cannot access their environment or respond meaningfully to stimulation. Ensure arms are free, stimuli are limited, the face is clean, and the mouth is suctioned as needed before beginning. Screen for confounders before interpreting any assessment findings — medications, fever, delirium, and recent procedures can all suppress conscious awareness. See the Disorders of Consciousness page for a full confounder list. Incorporate CRS-R items into treatment to more objectively track change over time.
Suggested Interventions
- PROM and/or splinting to prevent contracture
- Sensory stimulation across modalities
- Positioning for upright tolerance, respiration, and skin integrity
- Family and caregiver education on interventions and rationale
- Progression toward preparatory activities and ADL as arousal improves
Sensory Stimulation
Sensory stimulation is used to improve arousal and awareness. Research suggests that bimodal (auditory + tactile) or multimodal (all five senses) strategies impact attention and cognition. Start early and frequently — 3–5 times per day for 15-30 minute sessions — until more complex task participation is possible (Padilla & Domina, 2016).
Multimodal cues paired with action or initiation cues may increase the level of consciousness and environmental awareness. Identify which sensory modality the patient responds to best and use it to facilitate arousal at the start of each session.
The overall goals of sensory stimulation are to:
Increase arousal and attention to allow the patient to perceive incoming stimuli
Improve the quantity and quality of responses
Provide opportunities for the patient to respond to the environment
Channel heightened responses into meaningful activity over time
Guidelines for Sensory Stimulation
- Ensure the patient is comfortable and eliminate environmental distractions before starting
- Allow extra time for the patient to respond — 30–60 seconds per cue is appropriate
- Keep sessions short but frequent (15–30 min), alternating stimulation with rest
- Less aroused patients may need more intense or general stimulation initially; downgrade as arousal improves
- As responsiveness increases, focus on improving frequency of response, duration of alertness, response variety, and quality of environmental attention
- Stimulate all sensory modalities and select meaningful, patient-specific stimuli
- Involve family and friends — familiar voices and preferred stimuli are more effective (Padilla & Domina, 2016)
Position & Movement
Principles
- Faster movement tends to facilitate arousal
- Use meaningful and familiar position changes
- Avoid spinning (may trigger seizures)
- Watch for protective or delayed balance reactions
- Monitor vital signs with all position changes
Activity Ideas
- Vestibular: rolling in bed, bed mobility, transfers
- Proprioception & kinesthesia: weight-bearing, joint compression, ROM, positional changes, tilt table, side-lying
- Postural alignment: facilitate normal alignment and symmetrical positioning throughout
Auditory
Principles
- Allow only one person to speak at a time
- Assess the patient's ability to localize sound before testing responsiveness to sound location changes
- Familiar voices are more effective than unfamiliar ones (Padilla & Domina, 2016)
Activity Ideas
- Call the patient by name
- Familiar music, TV shows, or audiobooks
- Family member's voice (recorded or live)
- Environmental sounds: clapping, bell, whistle
Tactile
Principles
- Tactile input can be facilitatory or inhibitory — observe response and adjust
- The face (lips and mouth) is the most sensitive area
- Vary pressure: firm pressure vs. light touch produce different responses
- Avoid ice to the face or body — may trigger a sympathetic nervous system response
- Use noxious stimuli (e.g., sternal rub, pinprick) with caution and clinical judgment
Activity Ideas
- Sternal rub
- Variety of textures: clothing, blankets, stuffed animals, lotion
- Variety of temperatures: a metal spoon dipped in hot or cold water for 30 seconds
- Familiar objects placed in the hand (comb, toothbrush)
Olfactory
Principles
- Hold the scent near — do not touch it to the skin
- Provide stimulation for ~10 seconds per trial
- The olfactory nerve (CN I) is the most commonly injured cranial nerve after TBI
- Tracheostomy eliminates airflow through the nostrils and inhibits the sense of smell
- Nasogastric tubes can also block olfactory input
Activity Ideas
- Pleasant: aftershave, perfume, coffee grounds, favorite foods
- Noxious: garlic, mustard
Avoid vinegar and ammonia — both can irritate the trigeminal nerve (CN V).
Gustatory
Principles
- Provide stimulation to the lips and area around the mouth
- If the patient is defensive (pursing lips, closing mouth, pulling away), gently continue stimulation to decrease defensive reactions and increase awareness
- Be aware of diet restrictions and bite reflexes before proceeding
- Coordinate with SLP regarding oral stimulation and aspiration risk
Activity Ideas
- Cotton swab dipped in sweet, salty, or sour solution
- Oral stimulation during mouth care
Avoid sweet stimuli if the patient is having difficulty managing secretions.
Visual
Principles
- Provide normal visual orientation — position the patient to see the room and environment
- Eliminate distractions before attempting visual tasks
- Establish fixation before attempting tracking
Activity Ideas
- Tracking: colored penlight, familiar faces, photos of family members
- Self in mirror
- Visual threat to assess blink response
- Scanning practice once tracking is established
Positive & Negative Responses to Sensory Stimulation
Monitor the patient's responses during and after stimulation. If negative responses occur, reduce intensity, pause, and reassess. Document all responses to track change over time.
Positive Responses
- Eye opening
- Blinking
- Direct response to stimulus (pushing away or attending to it)
- Following commands
- Increased arousal or movement
- Increased muscle tone
- Grimacing or crying
- Vocal utterances (e.g., moaning)
- Swallowing
- Calming effect
- Respiration rate increases then stabilizes
Negative Responses
- Absence of any response
- Agitation
- Startle followed by posturing
- Sudden decrease in arousal
- Yawning
- Bite reflex or tightly pursed lips
- Flushing or perspiration
- Increased salivation
- Seizure activity
- Sustained increase in HR, RR, and/or ICP
References
Cluck, J., & Otr, M. M. (2015, June 29). Activities for stimulation of persons with low arousal. http://s3.amazonaws.com/arena-attachments/715662/060c23188c291627d8f659d068607996.pdf?1474669884
Esbrook, C., Laxton, L., & Morrow, M. (2024). Critical care and early rehabilitation. In H. Smith-Gabai & S. E. Holm (Eds.), Occupational Therapy in Acute Care (3rd ed., pp. 115–137). AOTA Press.
Hamby, J. (2017). The Nervous System. In H. Smith-Gabai & S. E. Holm (Eds.), Occupational Therapy in Acute Care (2nd ed.). AOTA Press.
Holm, S. (2017). Early Mobility and Rehabilitation. In H. Smith-Gabai & S. E. Holm (Eds.), Occupational Therapy in Acute Care (2nd ed., pp. 663–672). AOTA Press.
Hamby, J. R. (2024). The nervous system, part 1: Traumatic brain injury, spinal cord injury, and stroke. In H. Smith-Gabai & S. E. Holm (Eds.), Occupational Therapy in Acute Care (3rd ed., pp. 365–448). AOTA Press.
Padilla, R., & Domina, A. (2016). Effectiveness of sensory stimulation to improve arousal and alertness of people in a coma or persistent vegetative state after traumatic brain injury: A systematic review. The American Journal of Occupational Therapy, 70(3), 7003180030p1-7003180030p8. https://doi.org/10.5014/ajot.2016.021022