Toward Accessible and Multimodal Diagnosis of Disorders of Consciousness: Integrating Clinical and Autonomic Markers

BACKGROUND: Disorders of consciousness (DoC) remain among the most challenging conditions in neurorehabilitation, with misdiagnosis rates approaching 40% and major implications for treatment planning, prognosis, and ethical decision-making. Current European and American guidelines recommend standardized behavioral assessments and, where available, advanced neuroimaging and neurophysiology. However, cost, limited access, and patient instability constrain implementation, leaving advanced assessments largely restricted to specialized centers. This diagnostic gap underscores the need for complementary approaches beyond behavioral scales or advanced imaging alone. Bedside behavioral tools, although indispensable, may fail to capture covert awareness or cognitive-motor dissociation. Conversely, reliance on high-technology investigations risks exacerbating inequities in structurally constrained healthcare systems. OBJECTIVE: We propose a hybrid clinical-physiological assessment model combining standard behavioral assessments, including the Coma Recovery Scale-Revised, Motor Behavior Tool-Revised, and Nociception Coma Scale, with autonomic and neurophysiological markers of central autonomic network function. METHODS: The structured workflow, consolidated in clinical practice, includes baseline autonomic recordings before and during standardized behavioral testing, repeated weekly during the first month and biweekly thereafter. Family involvement at scheduled intervals contextualizes behavioral responses and informs communication strategies. RESULTS: By fostering cross-modal convergence, this complementary framework enhances diagnostic certainty, supports tailored rehabilitation, and strengthens ethical transparency. CONCLUSIONS: While not yet validated as a formal protocol, it offers a scalable, cost-effective strategy adaptable across healthcare settings. Multicenter validation is recommended to confirm its generalizability and promote equitable integration of bedside physiological assessment into DoC care.