In this video, Beth Hansen, PT, DPT, explains how rehabilitation teams support communication as patients begin to emerge from a disorder of consciousness.
Beth describes how therapists look for consistent, purposeful behaviors—such as command following or object identification—and build on them to establish reliable yes/no communication. She shares practical strategies, including hand signals, switches, visual cues, and adaptive tools, to ensure patients can clearly express understanding and preferences.
The video highlights how clear communication allows patients to become more engaged, motivated, and participatory, helping restore autonomy and guide therapy decisions as recovery progresses.
Full-screen Title
How do you communicate with a patient who is emerging from a disorder of consciousness?
With Beth Hansen, PT, DPT
Lower Third
Beth Hansen, PT,
DPT Therapy Manager,
Spaulding Brain Injury Program Spaulding-Harvard TBI Model System
In the beginning we're really focusing on activity tolerance, looking for that consistent behavior that we can engage in a communication style. And then as they start to emerge, we can see that they're command following or identifying objects. Those are two key components to us officially saying someone's starting to emerge from being in a minimally conscious state. So we're looking for those kind of behaviors and then really capitalizing on them to see if we can turn it into a communication tool; and then we're able to do a lot more with those patients. If they can consistently say yes/no, we can engage them in preferred activities. Even patients at that level of consciousness are more motivated or more participatory if it’s something they’re interested in doing.
Sometimes once patients have some movement, they might do it just kind of when they're resting in bed. So we observe that as well to make sure that the behavior that we're seeing is not just a resting behavior also. And then we actually quantify. We want a full thumbs up. So we're looking for that height of the thumb movement as opposed to more of like, do we see them almost rubbing their thumb or things like that because we need to have a definitive yes. This would be a yes, and then maybe a tuck would be a no. Or if they can do kind of a neutral or a thumbs down for an absolute no. That is so important to do. So a very clear thumbs up and a very clear neutral or a thumbs down if they can move their arm that much.
The other things that we've done is do a switch. So if they have any movement in their arm that they can tap a switch for a yes and then tap it again for a no so that it's clear to us what they're actually trying to communicate. That is one thing that we've done. We've also done very simple things where we use an arm skate; so it has wheels and it takes away some of the friction; and we can say like, okay, you're going to move your arm to the right, to the no, and we'll have a visible cue for them. Move your arm to the left for a yes. And again, there'll be a visible cue for them, either the word or green for yes, red for no. Something along those lines.
I think that's important because we need to know they're really understanding kind of what we're requesting from them, and we may start to ask them some bigger questions if we are sure they're saying yes and no to us. So more things about treatment preference. Are they comfortable in their wheelchair? Do they want to do walking today or do they want to practice sitting … some things that will allow them to be more participatory and to engage them as the autonomous beings that we hope they'll get to, get back to being
Produced by the Model Systems Knowledge Translation Center (MSKTC), this story is part of the Recovering from Disorders of Consciousness Hot Topic Module. The content of this video is based on research and/or professional consensus. This content has been reviewed and approved by experts from the Traumatic Brain Injury Model System (TBIMS) centers, funded by the National Institute on Disability, Independent Living, and Rehabilitation Research, as well as experts from the Polytrauma Rehabilitation Centers (PRCs), with funding from the U.S. Department of Veterans Affairs. The content of the video has also been reviewed by individuals with TBI and/or their family members.
Disclaimer: This information is not meant to replace the advice of a medical professional. You should consult your health care provider about specific medical concerns or treatment. The contents of this video were developed under a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR grant number 90DPKT0009). NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS). The contents of this video do not necessarily represent the policy of NIDILRR, ACL, or HHS, and you should not assume endorsement by the federal government.
Copyright © 2026 Model Systems Knowledge Translation Center (MSKTC). May be reproduced and distributed freely with appropriate attribution. Prior permission must be obtained for inclusion in fee-based materials.
About the author: Model Systems Knowledge Translation Center (MSKTC)
The Model Systems Knowledge Translation Center (MSKTC) is a national center operated by the American Institutes for Research® (AIR®) The MSKTC collaborates with Model System researchers to translate health information into easy to understand language and formats for people living with spinal cord injury (SCI), traumatic brain injury (TBI), and burn injury and those who support them.
