The Milestones programs are designed for individuals who have sustained severe brain injuries with minimal and ambiguous responding.  During this sometimes protracted period of coma emergence responding is often difficult to interpret. The individual regaining consciousness may produce only one identifiable response, such as a finger flexion.  It may not be certain if this movement is a purposeful, directed act and so the Milestones begin with Unsignalled and Signaled Baseline measurement. 

         The state of the art in coma rehabilitation is known as "sensory stimulation". Important as stimulation might be, it alone does not supply a progressive system for capturing and reinforcing the individual's response capabilities. This series of programs emphasizes the gradual establishment of directed intentional acts on the part of the person emerging from coma. The strategy is to begin with whatever limited responding is available, and to build on that ability via definable steps we characterize as milestones:

• 0 Baseline -- inconsistent, ambiguous responding
• 1 Single discrete response
• 2 Controlled repetition of a response
• 3 Temporal pattern of responding
• 4 Contingent responding
• 5 Differential responding

          In addition to programs identified explicitly with the coma emergence milestones,

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-- BASELINES: Signalled & Unsignalled

          "BASELINE" actually consists of two tasks: UNSIGBAS (Unsignalled Baseline) and SIGBAS (Signalled Baseline)
These help determine if responses are occurring prior to and without intervention. The signalled baseline procedure permits a quantitative appraisal of responding which occurs to triggering stimuli prior to intervention or training, for example, an eye blink to a puff of air or a loud noise. Unsignalled baseline is a procedure to facilitate a quantitative appraisal of spontaneous response production without triggering stimuli and before training.

-- POUNCE: Milestone 1 - Single Discrete Responding

          At the first milestone of response competency is the ability to make a simple consistent response. Stimuli may be auditory, visual, or both. This task was developed to work with persons at Milestone 1 (Single consistent response) of coma emergence. The intent is to bring the process of responding into an objective sphere. Responses can be anything a switch can measure - limited only by the ingenuity, resources and technical expertise of the therapist.  The response can be made on the left mouse button or any momentary contact switch that mimics the action of a mouse.  Particular attention should be paid to the positioning of the patient and the mounting of the switch. We would urge consultation with an Assistive Technology specialist / Rehabilitation Engineer and Occupational Therapist. POUNCE presents visual or auditory stimuli to which a single response is made. The visual portion of POUNCE is simple and centered on the screen. Look for and attempt to train:

1. rapid onset of response
2. prompt release and
3. no repeats.

-- HOW MANY: Milestone 2 - Controlled Repetition of a Response

          HOW MANY requires response competency at the second milestone, namely a controlled number of repetitions of a single response. Switch or mouse presses can be used. HOW MANY requires response competency at milestone #2 (Controlled repetition of a response). This level of response competency is a precursor to training yes-no communication where one tap means "no" and two taps means "yes The HOW MANY program presents a series of flashing squares or tones, or both, followed by an opportunity to tap out a corresponding number of times, e.g., hear three beeps, tap three times on the switch. An example would be: S = BEEP BEEP BEEP -- R = TAP TAP TAP
          In order to do the HOW MANY task, one must a) keep track of number and b) stop responding when number is reached.

-- PATTERNS: Milestone 3 - Temporal Pattern of Response

          Here, a patterned response sequence must be produced in response to a model. Not only the number, but the timing of the responses is important. This task reflects competency at the third milestone of response competency. PATTERNS calls for the ability to repeat a patterned series of responses. This task requires memory for the pattern and the ability to execute it. It is the defining task for the third milestone of response competency. Because stimuli can be visual (light flashes) or auditory (beeps), the PATTERN procedure can be conducted as the AVIT (Auditory Visual Integration Task). Added to the requirements HOW MANY is the ability to control the timing of the response. For example: Stimulus = BEEP (PAUSE) BEEP BEEP Response = TAP (PAUSE) TAP TAP (not TAP TAP TAP) Appropriate pausing is now required. Visual and auditory stimuli can be selected.

-- GONOGO: Milestone 4 - Contingent Responding

          This task calls for contingent responding, the 4th milestone of response competency. A switch or mouse press is to be made only to certain stimuli. In GONOGO inhibitory control is required. A practical example is continuing through the intersection if the light is green, but pressing the brake when the light is red. In GO-NO GO the individual is required to respond only if certain conditions are present, and inhibit the response otherwise. For example: + stimulus or high tone --> Respond - stimulus or low tone --> Don't respond.

-- DIFFERN: Milestone 5 - Differential Responding

          This task addresses the fifth and final milestone of response competency: the ability to make different (but equivalent) responses to different stimuli. This program requires switch input. The last milestone is represented by the ability to make differential responses depending on the nature of the stimulus. Operationally, it differs from milestone #4 (contingent responding) by the addition of another switch. For example: + stimulus or high tone --> Respond, right hand - stimulus or low tone --> Respond, left . A series of trials proceeds with random inter trial intervals. Although the exact series is unpredictable, overall, there is a balance between the two types of stimuli. Throughout the series of programs, the computer keeps track of the individual's scores and conditions selected. At any time, one can exit from the procedures, retaining whatever results are already obtained.