Most patients follow a general pattern of recovery after a severe brain injury. This pattern is divided into stages. It is important to know each patient is different and may not follow the stages exactly. Patients vary in the amount of time spent at each stage and their recovery may stop at any stage. Recovery may be grouped into the following four stages:

Stage 1: Unresponsiveness: During this stage the patient does not respond consistently or appropriately. You may hear this stage referred to as a coma. You may notice different movements in the patient. These are referred to as reflexive or generalized responses.

• Decerebrate: A reflex that causes straightening of the arms and legs.

• Decorticate: A reflex that causes bending of the arms and straightening of the legs.

• Generalized responses: Random movement of the arms and legs for no specific reason.

Stage 2: Early Responses: During this stage the patient starts to respond to things that are happening to them. The responses will be more appropriate, but may be inconsistent or slow. The patient will start to have localized responses and follow simple commands. Some examples of early responses to watch for are:

• Localized response: These are appropriate movements by the patient in response to sound, touch, or sight. Turning toward a sound, pulling away from something uncomfortable, or following movement with the eyes are examples.

• Following simple commands: Opening and closing eyes, sticking the tongue out, or gripping and releasing hands when asked are examples.

Stage 3. Agitated and Confused: At this stage the patient is responding more consistently. The patient will be confused about where he or she is and what has happened. The patient will have difficulty with memory and behavior. The patient's confusion may lead to yelling, swearing, biting, or striking out. Do not be alarmed if soft wrist and ankle ties are used to protect the patient and prevent tubes from being pulled out.It is very important to remember this stage is a step toward recovery and this behavior is not intentional.

Stage 4. Higher Level Responses: The patient completes routine tasks without difficulty, but still needs help with problem solving, making judgments and decisions. The patient may not understand his or her limitations and safety is a big concern. Unusual or high stress situations make activities more difficult. The patient may seem more like the person you knew before. However, there may be personality changes.

Unfortunately, there is no way to predict how long a person will remain in one stage or what the final outcome will be. The team will work during the hospital stay to achieve the best possible outcome.

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