UPMC Rehabilitation Institute Disorders of Consciousness Program Interview Series: Kevin Franzese, DO
November 6, 2026
The Disorders of Consciousness (DoC) program at the UPMC Rehabilitation Institute provides specialized inpatient rehabilitation for patients, their families, and caregivers who remain in an unresponsive wakefulness syndrome or a minimally conscious state after suffering a severe brain injury. The multidisciplinary program treats the family as the unit of care, and family members take part in the patient’s assessment, therapy, and training for how to care for the individual from admission through the transition to home or, if needed a long-term care facility.
The six-week inpatient rehabilitation program is organized around two goals: improving the patient's level of wakefulness and preparing the family to bring the patient home at whatever level of function the patient has reached during rehabilitation. Currently the program operates in two locations, at the UPMC Mercy and UPMC Williamsport.
Kevin Franzese, DO, assistant professor of Physical Medicine and Rehabilitation, has been a member of the DoC program's clinical team at UPMC Mercy since 2018. In addition to his clinical role in the department of Physical Medicine and Rehabilitation, Dr. Franzese also is associate director of the Brain Injury Medicine Fellowship program.
In the interview below, Dr. Franzese discusses the philosophy of the program’s treatment approach, the challenges patients and families experience during the recovery and rehabilitation process, and how the DoC program works to help the family unit adjust to their new reality.
Q: Who are the patients the DoC program is designed to help?
A: Our DoC program is designed for patients and their families who have suffered severe brain injuries, be it through a traumatic event like an automobile accident or fall, or a brain injury resulting from prolonged hypoxia, which can occur after a heart attack, or drowning. We consider patients in disorders of consciousness at the level of unresponsive wakefulness syndrome (UWS, sometimes also called a vegetative state), or a minimally conscious state (MCS). We don’t consider patients in coma unless they rise to a higher level of consciousness.
The defining feature of our patient population is that they are not able to actively participate in the traditional rehabilitation process. A patient in UWS will react to what's happening around them but don’t show any awareness of it. Patients in a MCS will partial, inconsistent awareness of the world around them, for example, by tracking an object or following a command, or some can communicate. As with many conditions, there is a spectrum of what we see. Really, no two patients are identical. But neither patients with UWS nor MCS can engage with a therapist the way a typical rehabilitation patient does, so nearly everything we understand about them has to come from careful assessment and observation.
Those same limitations are what has historically kept these patients out of traditional inpatient rehabilitation programs. Acute inpatient rehab programs or the insurers who pay for them generally require that a patient be able to take an active part in therapy at a high level of intensity, and these patients can't meet that standard. Historically, many of them went from the hospital straight to a nursing home, where their outcomes were poor, and missed the opportunity for rehabilitation entirely.
That dynamic is, to put it mildly, suboptimal, and one of the reasons our program exists.
Q: How was the DoC program developed to address that gap?
A: The program grew out of a collaboration with the UPMC Health Plan. Because the UPMC Rehabilitation Institute and the UPMC Health Plan are closely connected, we were in a position to propose a different approach for these patients. Rather than discharging them to a long-term care facility, we would invest resources in their rehabilitation up front, with the goal of getting them home.
We made the case that this approach would benefit patients and their families, who would have the opportunity for rehabilitation and, ultimately, a better quality of life at home. It would also be a more efficient use of resources than long-term institutional care, which is considerably more costly over time. The health plan agreed, and that commitment is what allowed us to build the program as we did.
That degree of integration is uncommon, and it sets our program apart. It allowed us to design a six-week program, which is considerably longer than a typical DoC rehabilitation program. With this patient population, that additional time matters because a meaningful part of it is spent getting to know each patient in order to direct their rehabilitation more effectively.
Q: How is the six-week inpatient program structured?
A: Many of our patients come to us after having been taken care of within the UPMC system, so our Brain Injury Medicine service has often been involved in their care before they are admitted to the DoC program. Even so, we devote the first few weeks to getting to know each patient thoroughly. That process includes clinical assessments, laboratory testing, and imaging. We work to optimize the patient's medications and manage any medical conditions that may be suppressing arousal or limiting their ability to participate in therapy. We use stimulant medications aggressively during this phase, along with other agents, to promote wakefulness.
Once the initial assessment is complete, we meet with the family to review our findings and explain where we believe the patient is in terms of level of consciousness. That conversation sets the direction for the rest of the rehabilitation program. From there, the medication regimen and the therapy program are both directed toward maximizing the patient's wakefulness. If a patient emerges from MCS over the course of the program, we transition them to a traditional rehabilitation approach.
Sleep is an equally important part of that effort, because good sleep is the foundation of being able to be awake. Sleep-wake cycles begin to return as patients improve, though they are usually fragmented, so most of our patients receive a sleep medication regimen combined with a behavioral one. We keep them awake and out of bed during the day and do our best not to interrupt their sleep at night.
Throughout the six weeks, we also prepare the family to bring the patient home. A patient who makes substantial progress and goes home with family is an obvious success. But even when a patient does not progress much, we can train the family and prepare the home to receive the patient at a very low level of function. Returning home and to their community under those circumstances is, as far as we are concerned, a success as well.
Q: Why does the program treat the family as the unit of care?
A: Philosophically, we view a severe brain injury as something that happens to the entire family. The patient sustains the injury, but the family suffers the wound. Their lives are changed by it as well, and they will carry much of the responsibility for the patient's care long after they leave our hospital. For that reason, our program’s education and our rehabilitation process are directed at the entire family. We expect family members to take an active part at every stage of the rehabilitation, be it in physical therapy, training, learning about their loved one's condition, and in the emotional process of coping with what has happened.
There is a practical dimension, too. Because our patients cannot communicate with us, or can only communicate in limited ways, the family is our primary source of information about the person. They know the patient far better than we do. With many of my patients, the severity of the injury means I will never really come to know them as the people they were before. Everything I learn about who that person comes from the family, and that knowledge shapes how we approach their care. Indeed, it is often the most important information we can get.
Q: What do you need to learn from families, and how does that information shape the patient's therapy?
A: I want to understand who the person was before the injury – their personality, interests, and what would have motivated them to get up and do something. Those are the things we will try to draw on during rehabilitation. For one patient, it may be a kind of music. For another, it may be a favorite form of entertainment, or simply a style of engagement they have always responded to. We also encourage families to make the patient's room their own by bringing in photographs and belongings from home and playing the music the person enjoys.
Familiar voices are one of the cornerstones of DoC rehabilitation, and we use that as much as we can to our advantage. We ask families to have the people in the patient's life record stories, anecdotes, and messages that carry emotional significance for the patient, and we play those recordings during their inpatient admission. The research on this is clear in that patients respond to voices they know more than to the voices of strangers. I am someone this person has never met, so why would they want to engage with me or follow my commands? But if it is their daughter or their parent speaking to them, there is an emotional connection, and that has a much better chance of reaching them.
In the end, our rehabilitation approach comes down to finding a way to meet each patient where they are. That requires a lot of observation, flexibility, and willingness to learn from the family, because what works for one patient may have no effect on another.
Q: How do the different disciplines of the DoC program contribute to a patient's rehabilitation process?
A: Every discipline has a role to play, and their work overlaps considerably. In the early phase, physical therapists focus on range of motion and reconditioning. After a prolonged period of bed rest, many patients cannot tolerate being upright without becoming hypotensive, so therapists use a tilt table, or gradually increasing time sitting in a chair, to rebuild that tolerance. They also work to improve range of motion in the arms, legs, and neck, because many patients with severe brain injuries develop significant muscle tightness, and they fit each patient for a custom wheelchair suited to their needs. As tolerance improves, physical therapy progresses to weight bearing and, when possible, assisted walking.
Occupational therapists work on functional activities, guiding patients through the motions of dressing, bathing, and toileting, while paying attention to the hands and upper body. They also address range of motion in the upper body and aspects of visual dysfunction. Families also are trained in the hands-on care the patient will need at home, like managing incontinence or using a feeding tube.
Speech-language pathologists address swallowing, beginning with small trials such as ice chips and progressing to a formal radiographic swallow study if the patient shows a reflexive swallow. They are also responsible for administering the Coma Recovery Scale-Revised, the gold-standard measure our field uses to assess a patient's awareness and level of arousal. In addition, they look for ways to help patients with severe impairments communicate, whether through eye-tracking technology or other methods. Even a limited means of communication gives a patient some autonomy and some ability to participate in their own care.
Rehabilitation nurses keep patients clean, safe, and nourished. They administer medications and feedings to patients by the safest means, typically a type of feeding tube given the nature of a disorder of consciousness. They work to preserve range of motion and also care for wounds.
Neuropsychologists work with patients as their awareness improves, and they also provide counseling to family members as they cope with how their lives have changed. All of these disciplines work together, and the family is part of the process throughout.
Q: How does the DoC team prepare patients and families to return home?
A: Inpatient rehabilitation is only the first stage of a patient's recovery, and for many of these patients, it is a recovery that will continue for the rest of their lives. We plan each discharge comprehensively, so the patient does not lose momentum in the move from the hospital to their home.
The planning begins well before the discharge date. We work with a home modification service that visits the house to measure doorways and staircases, install lifts and ramps, and modify bathrooms as needed. The goal is to have everything in place before the patient arrives, so the family is set up to succeed from the first day.
At discharge, we arrange home care services. This usually includes physical, occupational, and speech therapy, along with a nurse, a social worker, and an aide. Having that team in the home lets us see how the family is managing and make adjustments if something is not working. As the patient settles in and the family establishes a routine, we transition from home-based therapy to outpatient therapy several times a week, and the patient continues to follow up with our team in clinic.
Q: What does the long-term recovery process look like for these patients?
A: It is something our field is still learning about. For a long time, many patients with injuries as severe as what we see now did not survive, or care was withdrawn early in the ICU, so there were relatively few patients to follow over the long term. As we have become better at keeping patients with traumatic brain injuries alive long enough to reach rehabilitation, we are caring for more of them and learning more about what recovery trajectories can look like long term – years or decades later.
The unfortunate reality is that many of these patients will live with significant disability for the rest of their lives. Some make no meaningful improvement. Many improve to some degree, and a good number reach a reasonable quality of life with assistance. A smaller group makes remarkable recoveries. I have had patients return to appearing almost entirely as they did before their injury, going on to have families, hold jobs, and return to school. That does not happen every day, but those outcomes are a powerful source of motivation for our team, given how many difficult outcomes we also see. Right now, we can’t really predict which patients will recover to that degree, but it is something the field and some of our own researchers are actively working on.
So, we take a pragmatic approach with our families. We prepare them for a long recovery in which the goal is to find a way to enjoy each day, rather than putting life on hold while waiting for the patient to get better, however they may define better. Many patients will not reach what the family hoped for at the outset. Most of our patients do find a quality of life that is acceptable to them, or at least workable, but it is rarely the life they had before.
Q: How Is the program's approach to assessing these patients evolving?
A: One of the most important developments in our field right now is a growing focus on whether patients are more aware than their bodies can show. This is known as cognitive motor dissociation, and a number of technologies are now being developed to detect what is called covert consciousness. They are designed to see if a patient is truly in an unaware state or is aware but unable to move or respond.
Our program is part of the effort to answer that question. We have been conducting research with a cap fitted with EEG electrodes that measures brain activity. In principle, a patient who cannot move may still be able to show us on the screen that they are paying attention to what we are doing, or that they are trying to follow a command. This technology is still in its infancy. Our current research is focused on understanding how the device works and if it can be used as a functional assessment tool. We believe it can, but there are no established protocols, and the device is not commercially available. Over the next several years, I expect tools like this to become more common in how we assess and interact with these patients, and in how we identify those who are aware.
If a patient is thinking complete thoughts but cannot respond or physically move, I feel a real urgency to find a way to communicate with them. The most important questions I want to ask are whether they want to continue with rehabilitation and what their goals of care are. Right now, every decision we make on a patient's behalf is based on what the family or we believe they would want, because they cannot tell us. Being able to give that control back to the patient, giving them back their autonomy over what happens to them at the most fundamental level, is an important ethical step.
Q: What do you see as the biggest opportunity in caring for these patients?
A: One of the biggest opportunities lies in advocating for these patients and their families. Because these patients cannot advocate for or speak on their own behalf, that means we have to help. Just letting the medical community know that these patients are out there can help keep them and their families from becoming invisible. The other side of that is trying to find ways and provide tools for our patients to live life on their own terms, according to their values rather than mine or anyone else’s. A program that fully prepares a patient and their family for life after a devastating brain injury is one step in that direction. These patients and families have already lost so much, our job is to give back whatever we can.
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