CLINICAL PRACTICE: CURRENT OPINION

Neuropsychological Assessment
and Management of People in States
of Impaired Consciousness:
An Overview of Some Recent Studies
Barbara A. Wilson,1,2 Martin R. Coleman3 and John D. Pickard3
1

Medical Research Council Cognition and Brain Sciences Unit, Cambridge, United Kingdom
The Oliver Zangwill Centre for Neuropsychological Rehabilitation, Ely, United Kingdom
3 Impaired Consciousness Study Group, University of Cambridge, United Kingdom
2

his article is concerned with patients in coma, the vegetative, or minimally conscious states. Studies addressing the issue of assessment and management of
these patients are described. These include (a) the development of an assessment
tool (Wessex Head Injury Matrix, WHIM); (b) use of the WHIM to assess the
effects of posture on arousal, showing that some 75% of patients show more
behaviours when assessed while they are in a standing frame than when supine;
(c) a comparison of the WHIM with the Glasgow Coma Scale, demonstrating that
the WHIM is more sensitive than the GCS for measuring the behavioural repertoire of people in states of reduced consciousness; (d) a discussion of situations
when neuro-imaging techniques are required to assess residual functioning; and
(e) the long term outcome of one of the first vegetative patients to be scanned
with Positron Emission Tomography (PET). We conclude with a discussion about
neuropsychology and patients in states of impaired consciousness.

Keywords: coma, vegetative state, impaired consciousness, assessment

In this article, we consider three groups of people

with impaired consciousness (wakefulness and/or
awareness) following brain injury: those in coma,
the vegetative state (VS) and the minimally conscious state (MCS). Coma in the absence of sedation or neuromuscular blockade is defined by
absent eye opening, evidence of sleep wake cycles
and no purposeful response to sensory or cognitive
stimuli. Reflex or withdrawal responses to sensory
stimuli are generally preserved (Royal College of
Physicians, 2003). The vegetative state is defined
by evidence of eye opening and sleep wake cycles,
but critically no evidence of purposeful response to
sensory or cognitive stimuli; reflex responses are
typically preserved (Royal College of Physicians,
2003). The minimally conscious state is defined by

preserved eye opening and sleep wake cycles, and

critically reproducible, but inconsistent evidence
of purposeful response to sensory and/or cognitive
stimuli (Giacino, Ashwal, Childs, Cranford,
Jennett et al., 2002).
Most people recover from coma within 4 to 6
weeks of ictus either regaining full consciousness or progressing to the VS or MCS. During the
acute phase they are likely to be assessed regularly using the Glasgow Coma Scale (GCS;
Jennett & Teasdale, 1976). This scale is the most
widely applied measure of wakefulness and
awareness in the acute hospital environment. It
consists of three subscales: best eye response,
best motor response and best verbal response.
Although Jennett and Teasdale suggest that the

Address for correspondence: Barbara A Wilson, MRC Cognition and Brain Sciences Unit, Box 58, Addenbrookes
Hospital, Hills Road, Cambridge CB2 2QQ, United Kingdom. E-mail: barbara.wilson@mrc-cbu.cam.ac.uk

28

BRAIN IMPAIRMENT
VOLUME

9 NUMBER 1 MAY 2008 pp. 2835

NEUROPSYCHOLOGICAL ASSESSMENT AND MANAGEMENT OF PEOPLE IN STATES OF IMPAIRED CONSCIOUSNESS

three subscales should be individually reported, it

is common for the scores on each subscale to be
summed (maximum score = 15). Although a score
of 7 or less on the GCS is consistent with the
behavioural definition of the comatose state, theoretically someone in a vegetative state could also
score 7 or less on the scale and someone in a minimally conscious state could score as little as 8. It
is this lack of clear distinction and thus sensitivity
to the critical behavioural repertoire of these conditions of impaired consciousness that has
prompted the creation of alternative behavioural
scales designed to specifically detect the key
behaviours distinguishing these patients.
It is important to differentiate between these
conditions, as management and rehabilitative
decisions might be made on the basis of the cerebral function and capacity inferred from such
measures. However, it is often difficult to differentiate between the vegetative and minimally conscious states, and a high rate of misdiagnoses has
previously been highlighted (Andrews, Murphy,
Munday, & Littlewood, 1996; Childs, Mercer, &
Childs, 1993). Neuropsychologists can help distinguish between the two. McMillan (1997)
describes a young woman who was thought to be
vegetative but when carefully observed showed
evidence of cognition. The reason for the assessment is because the health authority was considering going to court to request permission to remove
feeding and hydration. A further assessment of the
same woman a few days later (Shiel & Wilson,
1998) confirmed McMillans findings. This evidence of cognition was in contrast to some medical opinion at the time. One of the main reasons
for the difference of opinion was that the psychological observations had taken place over 2 days
rather than a half hour or so, and systematic trials
were conducted. The case was immediately
dropped. Recently McMillan and Herbert (2004)
presented a 10-year follow-up of this patient. She
now lives in the community with 24-hour support,
she speaks, initiates conversation, has a spontaneous sense of humour, expresses clear and consistent preferences, uses an electric wheelchair,
eats solid food and drinks though a straw. This
early work has contributed to the now accepted
assessment procedure for such patients. Patients
with impaired consciousness following brain
injury are now assessed over a prolonged period
of observation (> 6 weeks) by at least two independent doctors supported by the observations of
all professionals and family members in contact
with the patient (Bates, 2005). It is accepted that
observations should take place at different times
of the day, when the patient is in different posi-

tions (elevated or rolled versus supine) and that

the observations of everybody in contact with the
patient should be recorded and taken into account.
Traditionally neuropsychologists have had
little involvement with people who are in coma,
the VS or the MCS. This is a field where the medical profession, nurses, physiotherapists, occupational therapists and speech and language
therapists have had the greatest contact. Until
fairly recently, most neuropsychologists have
entered the scene only when patients have recovered consciousness. In the past few years, however, an increasing number of psychologists have
become involved in the assessment and management of patients in states of impaired consciousness (Crawford & Beaumont, 2005; McMillan &
Wilson, 1993; Shiel & Wilson, 2005). Neuropsychologists have, however, always been
involved in assessment, and these are skills we can
transfer to the management of vegetative and minimally conscious patients. Improvements in the
functioning of such patients are often very small
and gradual, and they can easily be missed if one
is not looking for them or monitoring the situation
very closely. If hospital or nursing home staff and
family believe that patients are showing no change
over weeks or months, they may become disillusioned and poorly motivated. Good measures to
identify change can influence clinical practice and
facilitate rehabilitation.
In this article we consider some ways in which
neuropsychologists can, as part of a multidisciplinary team, aid in the assessment and management of people in states of impaired consciousness.
We consider different types of assessment for such
people beginning with a behavioural assessment,
The Wessex Head Injury Matrix.

The Wessex Head Injury Matrix (WHIM)

The origins of the WHIM go back to 1980 when
one of us (BAW) was asked to assess a woman
who, following an anaesthetic accident, was left
blind, dysphasic, hemiplegic and apraxic. Thus
she could not see, speak or move one side of her
body. The other side of her body did not do what
she wanted it to do. When BAW was asked to
assess the level of her cognitive functioning, she
thought, I can assess people who cannot see or
who cannot speak or who cannot move but surely
they had to do one of these things? She did not
dare say, however, that the woman was untestable,
having been taught during her training that we
should Never say a patient is untestable. It says
more about the psychologist than it says about the
patient (Yule personal communication,1976).

29

BARBARA A. WILSON, MARTIN R. COLEMAN AND JOHN D. PICKARD

Instead she decided to use the Portage

Developmental Checklists (Bluma, Shearer,
Frohman, & Hilliard, 1976) developed for use
with preschool developmentally delayed children.
There are five checklists covering the functions of
socialisation, cognition, motor behaviour, language and self care skills. Each checklist looks at
typical behaviours seen in nonhandicapped children from birth to 6 years of age. In typical circumstances the psychologist visits the child at
home and observes the child with the parents in
order to complete each scale. Developmental gaps
are identified and goals are set to try to achieve
these missing behaviours. In the case of the particular adult patient referred to the first author, she
was observed over several sessions when working
with her occupational, physical and speech and
language therapists. On each scale she scored
below the level of an average 2-year-old. The first
treatment goals were determined by her failures
on the self-help check list.
There are, of course, other assessment tools
designed for use with adults with severe brain
injury such as The Glasgow Outcome Scale
(Jennett & Bond, 1975), the Rancho Los Amigos
Scale (Malkmus, Booth, & Kodimer, 1980) and
the Neurobehavioural Rating Scale (Levin, High,
& Goethe, 1987) but there are problems with
these. First, the categories are too broad to detect
subtle changes in behaviour. For example, the
Glasgow Outcome Scale has five categories and
the Rancho Los Amigos has eight. Second, the
behaviour may be appropriate to more than one
category. Thus in the Rancho Los Amigos Scale,
level 5 is confused inappropriate and level 6 is
confused appropriate, and some patients can
move from one category to another and then move
back again. Because of problems with existing
scales a new scale was needed.
The WHIM was developed following observations of 88 patients recovering from severe traumatic brain injury, and was a joint project between
two psychologists, a physiotherapist, an occupational therapist and a neurologist/medical rehabilitation specialist. Three types of behaviour were
observed: first, naturally occurring behaviour such
as a patient scratching her nose; second, a
response to something in the environment such as
looking at a nurse entering the room; and third, an
elicited response such as tracking a flashlight. In
total, 162 different items of behaviour were
observed from the 88 patients. As some only
occurred once and others seemed to overlap with
each other, we selected 62 items of behaviour for
the final scale (Shiel, Wilson, McLellan, Horn, &
Watson, 2000). There are several advantages to

30

this scale. Improvements in functioning following

severe brain injury are often very gradual and
unless one is looking for them they can be missed.
This can lead to poor motivation among staff and
poor patient care. Good measures to identify
progress can influence clinical practice.
The WHIM monitors subtle changes, it
reflects performance in everyday life, it can identify short-term goals, it identifies a sequence of
recovery and includes items of cognition, social
behaviour, communication and attention.
However, while the WHIM is a very helpful and
sensitive measure of behavioural repertoire and
changes to this portfolio, it does not directly distinguish between a patient in a vegetative or a
minimally conscious state. A behavioural scale
designed to do this is the JFK Coma Recovery
Scale (CRS; Giacino, Kalmar, & Whyte, 2004).
The CRS consists of six subscales addressing
auditory, visual, motor, oromotor, communication
and arousal processes with the individual subscale
items ordered in a hierarchical manner. The lowest
item on each subscale represents reflexive activity
while the highest items represent cognitively
mediated behaviours. The JFK Coma Recovery
Scale was developed to more extensively categorise patients functioning at Level I (generalised
response) to Level IV (confusedagitated
response) on the Rancho Los Amigos Levels of
Cognitive Functioning Scale. Another scale
specifically designed to assess and then direct the
rehabilitative strategy for these patients is the sensory modality assessment and rehabilitation technique (SMART, Gill-Thwaites & Munday, 2004).
With some similarities to the Rancho Los Amigos
Scales of Cognitive Functioning, it has been
extended and refined to accurately distinguish
vegetative and minimally conscious patients and
then direct and evaluate interventional treatments
to facilitate recovery.

The Effects of Posture on Arousal

Sensory stimulation programs have often been
claimed to promote arousal and behavioural
responsiveness in this client group (Jennett, 2002).
The content of these programs, however, varies
considerably from constant background stimulation (Wood, 1991) to intermittent use of specific
stimuli to effect senses such as auditory, visual,
olfactory, gustatory, tactile and physical (Oh &
Seo, 2003). While there is no conclusive evidence
that sensory stimulation can influence arousal and
awareness (Elliott & Walker, 2005), there is some
evidence that postural changes can be of benefit to
patients in the VS and the MCS (ibid). Using the

NEUROPSYCHOLOGICAL ASSESSMENT AND MANAGEMENT OF PEOPLE IN STATES OF IMPAIRED CONSCIOUSNESS

WHIM, 10 patients in the VS and 11 MCS

patients were assessed lying in bed, standing
using a tilt table at 85 and again lying in bed.
Three patients achieved the same WHIM highest
ranked behaviour (HR) observed score in both the
supine and elevated positions, but the remainder
showed improved HR scores when elevated.
These results can be seen in Table 1.
A Wilcoxon matched pairs signed ranks test
demonstrated a statistically significant difference
between lying and standing for the group as a whole
(p <.008). Despite this increase, most of the patients
still appeared to have little or no awareness of the
environment or of themselves. Nevertheless, the
observations suggest that positional changes may
influence behaviour in vegetative and minimally
conscious patients, revealing more of the patients
behavioural repertoire and ability. Most low awareness patients are assessed lying down but where
physical constraints permit, it may be appropriate to
also observe patients in the standing position to
maximise arousal and awareness and ensure accurate diagnosis. Positional change may be particularly
important when considering treatment withdrawal or
the ongoing nursing and therapy needs for placement of the patient (Jennett, 2002). There are, of
course, other advantages to using a tilt table for
patients in states of low awareness. As Elliott and
Walker (2005) state, it offers patients the opportunity
to achieve weight bearing, promotes more postural
awareness (Morgan, Cullen, Stokes, & Swan, 2003)
and stimulates visual, vestibular and somatosensory
systems. It has been shown to reduce lower limb
spasticity (Bohannon, 1993) and increase ankle
range of movement (Bohannon & Larkin, 1985). It
has also been shown to improve circulation

TABLE 1
WHIM Highest Ranked Behaviour: Supine Versus Standing
Supine
1
5
20
8
14
18
26
13
42
43
14
4

Standing
49
26
36
23
26
28
34
16
43
43
14
4

Note: WHIM = Wessex Head Injury Matrix

Difference
+48
+21
+16
+15
+12
+10
+8
+3
+1

(Bromley, 1985) and renal function (Duffus &

Wood, 1983), and assist in reducing osteoporosis
(Cybulski & Jaegar, 1986). These physical benefits
in combination with producing a heightened alertness could benefit this patient group, particularly in
the acute phase of rehabilitation.

A Comparison of The Glasgow Coma

Scale with the WHIM
In contrast to the WHIM, the GCS, showed no
changes in arousal or awareness between the
supine and standing conditions. Twenty patients in
states of reduced awareness, 10 in the vegetative
state and 10 in the minimally conscious state,
were administered the GCS and the WHIM. All
scored 10 on the GCS and thus looked very similar. On the WHIM, however, they were very different. There are two ways to score the WHIM.
First is the highest ranked (HR) behaviour (i.e.,
the highest of the 62 items). The second is the
total number of behaviours (TB) out of the 62.
Here the scores ranged from 1 to 47 for the HR
behaviour and 1 to 27 for the TB. Patients in the
MCS tended to score higher than those in the VS,
but there is some overlap. The fact that the WHIM
scores differentiate between the patients, while the
TABLE 2
A Comparison of Glasgow Coma Scale and the Wessex
Head Injury Matrix (Highest Response and Total
Behaviours)
Vegetative
CS
RL
DB
AH
NB
MB

GCS
10
10
10
10
10
10

WHIM HR
43
7
1
3
7
14

WHIM TB
14
5
1
3
5
8

Minimally conscious state

KW
FG
CC
ME
AA
CW

10
10
10
10
10
10

47
13
20
22
18
42

20
11
16
10
12
17

Note: Column 1 refers to the patients; GCS = Glasgow

Coma Scale score; WHIM HR = Wessex Head Injury
Matrix Highest ranked score; WHIM TB = Wessex
Head Injury Matrix Total number of behaviours.

31

BARBARA A. WILSON, MARTIN R. COLEMAN AND JOHN D. PICKARD

GCS did not, suggests that the WHIM is more

sensitive. The results can be seen in Table 2.
Cross-sectional construct validity, reliability
and sensitivity are well established with the GCS
(Rowley & Fielding, 1991), but its predictive
validity and use at monitoring subtle changes has
not been sufficiently studied (Horn et al., 1993;
Prasad, 1996). This view supports the work of
Majerus, Van der Linden and Shiel (2000) and
Shiel et al. (2000), who state the WHIM is more
sensitive than the GCS at measuring recovery and
monitoring subtle changes. Clinicians attempting
to diagnosise patients should ensure the most
applicable evaluation tool is used, to make certain
patients are categorised correctly.

When Behavioural Measures Might Be

Insufficient: Assessments of Residual
Function Through Neuro-Imaging
Techniques
Unfortunately the behavioural assessment of
patients in a vegetative or minimally conscious
state is often inhibited by the integrity of the
patients peripheral motor system, thus potentially
affecting the patients ability to respond to command. Although likely to affect only a small
number of patients to the degree of preventing
accurate behavioural assessment, the incidence of
peripheral spasticity and/or cranial neuropathies is
high in this patient group. Hence, an absent
behavioural response to command during assessment with the SMART, CRS or WHIM does not
necessarily rule out the possibility of underlying
cognitive integrity. Under these circumstances,
brain imaging paradigms using positron emission
tomography (PET) or functional magnetic resonance imaging (fMRI) are increasingly being
recognised as useful additions to the assessment
of these patients (Giacino, Hirsch, Schiff, &
Laureys, 2006). Using a range of sensory and cognitive stimuli PET and fMRI paradigms have
revealed preserved covert islands of cognitive
function in several patients behaviourally considered to fulfil the criteria for the vegetative state
(Boly, Faymonville, Peigneux, Lambermont,
Damas, et al. 2004; Giacino et al., 2002; Laureys,
Schiff, & Owen, 2004; Owen & Menon, 2002,
Owen, Coleman, Menon, Berry, Johnsrude et al.,
2005; Owen Coleman, Boly, Davis, Laureys, &
Pickard, 2006) as well as recovery of function
(Schiff, Rodriguez-Moreno, Kamal, Kim, Giacino
et al., 2005). The most recent demonstration of the
potential of brain imaging to inform the assessment of patients with impaired consciousness is
by Owen et al. (2006). They report the case of a

32

23-year-old woman, behaviourally meeting the

diagnostic criteria for the vegetative state 5
months after a traumatic brain injury. Although
unresponsive to command this patient was initially assessed using an fMRI auditory comprehension task, where she was presented with
sentences containing either ambiguous or unambiguous words, signal correlated noise or periods
of silence. At the most basic level, the patient
showed appropriate superior temporal activation
to hearing sound versus silence, at the mid-level
the patient also showed greater activation to hearing sentences versus signal correlated noise, and
at the highest level the patient showed appropriate
medial frontal and parietal activation consistent
with the retrieval of semantic information and
therefore speech comprehension. Although potentially subconscious processes, even at this level
the patient demonstrated behaviour inconsistent
with the diagnostic criteria for the vegetative state
and not visible behaviourally. However, it was the
following fMRI paradigm applied to this patient
that really underlined the potential of brain imaging to reveal residual covert cognitive function.
Owen et al. (2006) asked the patient to imagine
playing tennis and to imagine visiting all the
rooms of her house. When asked to imagine playing tennis significant neural activation was
observed in the supplementary motor area and
when asked to imagine visiting the rooms of her
house significant activity was observed in the
parahippocampal gyrus, the posterior parietal
cortex and the lateral premotor cortex. Indeed, the
neural responses in this patient were so clear they
were indistinguishable from healthy volunteers
performing the same tasks. The authors concluded
that These results confirm that, despite fulfilling
the clinical criteria for a diagnosis of the vegetative state, this patient retained the ability to understand spoken commands and to respond to them
through her brain activity (p. 1402). When this
study was published many casual observers commented that functional imaging would replace the
behavioural assessment of patients. This is not the
case; Owen and colleagues suggest imaging may
be a useful addition, but not replacement, to the
behavioural assessment of such patients, where
peripheral motor impairment cannot be excluded.
Indeed, functional imaging is only really helpful
to establish the presence of higher sensory and
cognitive function. It does not replace the valuable
visual observation of behaviours such as fixation,
orientation, habituation, localisation or tracking.
Moreover, functional imaging does not inform
decisions regarding withdrawal of nutrition and
hydration, where imaging results are negative, any

NEUROPSYCHOLOGICAL ASSESSMENT AND MANAGEMENT OF PEOPLE IN STATES OF IMPAIRED CONSCIOUSNESS

more than behavioural observations. That is, only

positive findings on imaging can be interpreted,
since false negative results occur in volunteers. At
present only a limited number of fMRI paradigms
have been developed to reveal covert sensory and
cognitive function and the absence of a response
on one test, does not exclude the possibility that
the patient could at another time or in response to
another modality, respond.

Long-Term Outcome of a Vegetative

Patient Demonstrating Residual
Cognitive Function on Brain Imaging
In 1998, Menon et al. used PET to study the covert
cognitive processing of a 26-year-old woman with
acute, disseminated encephalomyelitis described
as being in a persistent vegetative state. She
showed evidence of perceiving visual stimuli and
of processing these in that her responses to photographs of familiar faces differed from responses
to scrambled images with the same colours and
brightness. Between 5 to 6 months, after the onset
of the illness and 1 to 2 months after the PET scan,
the woman became increasingly responsive.
Eleven months post-onset, she went to a rehabilitation centre where she spent a further 11 months
before being discharged home under the care of
her parents in April 1999. At that time she was in
a wheelchair, was tube fed, communicated with a
letter board and 1 year later had a tracheostomy
tube fitted.
Every few weeks she spent a period in respite
care, and 2 years post-onset she was referred for a
neuropsychological assessment to determine the
level of her cognitive functioning. She completed
tests through pointing or spelling out answers on
her letter board. Essentially she was in the normal
range of ability for all the tests administered
(Wilson, Gracey, & Bainbridge, 2001). She was
also offered psychological support for the emotional consequences of her illness, to which she
responded well (MacNiven, Poz, Bainbridge,
Gracey, & Wilson, 2003). Ten years after the onset
of her illness this young woman remains in a
wheelchair, she is still tube-fed, she still has a tracheostomy in place and communicates with a
letter board (although her speech is a little easier
to understand), yet cognitively she is normal; she
is still making small but noticeable improvements
(e.g., she is now able to sit in an ordinary chair for
up to 2 hours at a time, she has learned to go to the
post box and the library alone). She leads a full
life and has written a book about her experiences
(Bainbridge, 2005).

Why Should Neuropsychologists

Be Involved in the Management
of Patients in States of Impaired
Consciousness?
Some of the earliest reports of neuropsychologists
working with low awareness patients appeared in
the
special
edition
of
the
journal
Neuropsychological Rehabilitation, edited by
McMillan and Wilson (1993). In 2005 Coleman
edited a second special issue of the same journal
on the same theme entitled, The assessment and
rehabilitation of vegetative and minimally conscious patients. Contributions came from many
different professions, including neuropsychologists. Neuropsychologists have always been
involved with assessment, and we can transfer
these skills to our work with any patient group.
Improvements in patients in low awareness states
may be very small and gradual; if we are not looking for them we may miss them and hospital and
nursing home staff may become disillusioned and
poorly motivated if they think patients are not
changing over weeks and months. They may say
No change even though appropriate measures
show there are small changes.
Good measures to identify change can influence clinical practice. Many neuropsychologists
are trained in clinical psychology first and then
specialise in neuropsychology. Clinical psychologists are experienced in behavioural observations
(indeed this was the basis of the WHIM). We also
use observations to make decisions in complex
cases such as the life-and-death case referred to
earlier and reported by McMillan (1997) and Shiel
and Wilson (1998). It is only too easy to think the
patient is unaware, if casual observations are the
basis for this decision. With structured
behavioural experiments such as those carried out
by Shiel and Wilson (1998), far more detailed
information can be obtained. Detailed observations can also be brought to bear on decision
making in complex cases such as whether or not a
patient has any cognitive functioning.
One of the main changes in neuropsychological rehabilitation over the past 2 decades has been
the recognition that rehabilitation starts in intensive care. Even though patients in the vegetative or
the minimally conscious state cannot be involved
in the negotiation of their long-term goals, we can
still set appropriate goals for our patients. We can
involve the families in the negotiation process, so
this is yet another area where clinical neuropsychologists have a part to play. Shiel (2003) says
the kind of goals one might set for these patients
include maintaining eye contact for 5 seconds or
looking at the person giving attention.

33

BARBARA A. WILSON, MARTIN R. COLEMAN AND JOHN D. PICKARD

It would seem therefore that there are at least

five reasons why neuropsychologists should be
part of the multidisciplinary team involved in the
care of low-awareness patients: namely, in the
assessment of the behavioural repertoire of these
patients, in the careful observation of change, in
helping to make decisions about the diagnosis, in
early goal setting with health care staff and families and in giving advice and help to families. The
emotional impact on the families after seeing their
relative in a long period of reduced consciousness,
may well be huge and stressful. Neuropsychologists trained in clinical psychology can
offer psychological support to help family members cope with loss and manage their grief for the
person they once knew. We cannot function efficiently, however, if we work in isolation. We need
to recognise the contributions of the medical profession, nurses, therapists, radiographers, dieticians, physiologists and other professions
contributing to good clinical care and research.
Coleman (2005) provides comprehensive coverage of this topic.

Conclusions
Neuropsychologists can use their skills to help in
the management of low awareness patients. We
need to work as part of a multidisciplinary team
and combine behavioural, imaging and physiological measures. We can help with compensation
claims, with life and death decisions and we can
help improve clinical diagnosis. We can also offer
emotional support and advice to families of those
people in states of impaired consciousness.

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