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Sensory Stimulation Program
Abstract
Taking care of patients recovering from coma is not easy, as current therapeutics are neither well developed nor well validated. Sensory stimulation programs are the most widely known treatment applied to severely brain-injured patients. In this chapter, we will introduce the theoretical principles underlying these programs and the studies assessing their clinical interest. We will also discuss the limitations of this treatment and consider future directions for clinical research.
... разработано много программ сенсорной стимуляции (психостимулотерапии). Однако доказательная база этого метода при работе с нарушениями сознания крайне ограничена и основывается на анализе частных случаев и методов работы [29]. Особый интерес в профессиональном сообществе вызывают исследования, где удалось добиться перехода из вегетативного состояния в состояние минимального сознания или в ясное сознание [15,30]. ...
INTRODUCTION. In the neuropsychological support of patients with impaired consciousness at an early stage of rehabilitation, methodological and practical problems arise related to the choice and procedure for using methods of neuropsychological diagnostics and neuropsychological rehabilitation. To develop methods of working with such patients, it is necessary to address the concepts of the structure of consciousness and the content of consciousness. RESULTS. The article presents a review of the literature devoted to the problem of the work of a neuropsychologist with patients with impaired consciousness. In the reviewed literature, attention is drawn to the insufficient development of the neuropsychological content of the concept of “consciousness”; methodological and procedural limitations that arise when a neuropsychologist works with patients with disorders of consciousness of varying degrees of severity; the possibilities of conducting and limiting psychostimulotherapy and sensory stimulation in domestic and foreign approaches are discussed. CONCLUSION. The analysis of publications on the topic of accompanying patients with impaired consciousness reflects the presence of a number of unresolved issues. At the present stage of development of neuropsychological work with patients with impaired consciousness, there is no single approved and detailed protocol regulating the conduct of neuropsychological diagnostics and neurorehabilitation with them. The problem is at the stage of solution and requires further research.
... The coma following brain injury produces sensory deprivation (Ansell, 1991), thus in order to prevent such additional detrimental effects on the already damaged brain, the rationale for treatment leads to enrich the environment and promote neural plasticity (Di & Schnakers, 2018). Interventional approaches resort to variations of multisensory stimulation such as multimodal stimulation of the senses (Canedo, Grix, & Nicoletti, 2002), music therapy (Formisano et al., 2001;Magee, 2007), or verticalization protocol using a tilted table with an integrated stepping device (Krewer, Luther, Koenig, & Muller, 2015;Frazzitta et al., 2016). ...
Background:
Neurosensory stimulation is effective in enhancing the recovery process of severely brain-injured patients with disorders of consciousness. Multisensory environments are found in nature, recognized as beneficial to many medical conditions. Recent advances detected covert cognition in patients behaviorally categorized as un- or minimally responsive; a state described as cognitive motor dissociation (CMD).
Objective:
To determine effectiveness of a neurosensory stimulation approach enhanced by outdoor therapy, in the early phases of recovery in patients presenting with CMD.
Methods:
A prospective non-randomized crossover study was performed. A two-phase neurosensory procedure combined identical individually goal assessed indoor and outdoor protocols. All sessions were video-recorded and observations rated offline. The frequency of volitional behavior was measured using a behavioral grid.
Results:
Fifteen patients participated in this study. The outdoor group patients had statistically significant higher number of intentional behaviors than the indoor group on seven features of the grid. Additionally, for all items assessed, total amount of behaviors in the outdoor condition where higher than those in the indoor condition.
Conclusions:
Although preliminary, this study provides robust evidence supporting the effectiveness and appropriateness of an outdoor neurosensory intervention in patients with covert cognition, to improve adaptive goal-oriented behavior. This may be a step towards helping to restore functional interactive communication.
... Sensory stimulation activates affected neural networks, maximizing the potential for neural reorganization through brain plasticity (Di and Schnakers, 2012;Pham et al., 2014). Sensory stimulation programs provide enriched environments that optimize stimulation to encourage experience-dependent changes to the brain at neuroanatomical and biochemical levels (Renner and Rosenzweig, 1987;Nithianantharajah and Hannan, 2006;Schreiber et al., 2014). ...
Children and youth with disorders of consciousness (DOC) are defined as those under 18 years of age who show wakefulness, but with absent or reduced awareness. This condition is considered to be prolonged when this state lasts for longer than four weeks. Hence, the term prolonged disorders of consciousness (PDOC) (Royal College of Physicians, 2013). Children and youth with DOC need care that can meet their highly complex needs. This care includes careful stimulation to elicit purposeful responses in assessment and evaluation, and managing an individual's environment optimally to meet their sensory needs. Accuracy in determining awareness is paramount due to several factors. First, ethical issues surround the provision of appropriate care (Ashwal, 2013) regarding the design and use of the type of sensory stimulation and the intensity of the intervention. Second, admission to rehabilitation programmes is affected by accurate diagnosis (Eilander et al., 2005), as this would ensure that those who could benefit are not excluded from admission to these programmes. Third, end-of-life decisions are critically dependent upon correct diagnosis (Ashwal and Cranford, 2002), when clinicians, families, and the legal system consider continuation or withdrawal of intervention in the light of the patients' pain and suffering and their prognosis for recovery.
Although guidance for working with adults with PDOC is available (Royal College of Physicians, 2013), there are no specific clinical guidelines for working with children and youth with PDOC. Recovery following brain injury in adults is better understood than in pediatric populations (Anderson and Yeates, 2010; Ponsford, 2013). This has resulted in theories about recovery of consciousness being based on adult brains, despite neurodevelopmental differences between child, and adult brains (Ashwal and Cranford, 2002; Perner and Dienes, 2003), particularly within the frontal lobes (Nicholas et al., 2014). This poses several problems for clinicians. Evaluation and treatment guidelines for rehabilitation with pediatric PDOC are adapted from those used with adults. However, guidance on adaptation is limited and dependent on clinicians' specialist knowledge, which is likely to be highly variable. The dearth of knowledge regarding neurological recovery from PDOC in childhood positions some theorists to argue that the immature brain is less susceptible to damage due to its plasticity, whereas others propose that the developing brain is more vulnerable to injury (Bower and Shoemark, 2012). Hence, more must be understood about recovery from brain injury in the pediatric population.
... SS programs are based on the idea that to avoid sensory deprivation you should organize an enriched environment which can promote neural plasticity (Di and Schnakers, 2012). However, following the tacit hypothesis that DOC patients have reduced attention capacities and that simple stimulation is less demanding in terms of cognitive processing, several SS protocols used simple and often meaningless stimulations. ...
Sensory Stimulation (SS) for patients with Disorders of Consciousness (DOC) refers to a corpus of approaches aimed at promoting arousal and behavioral responsiveness by the application of environmental stimuli (Giacino, 1996). Despite the different procedures adopted, the method invariably includes presentation of stimuli which are simple, frequent and repetitive, possibly autobiographical and with emotional content. Moreover, stimuli are administered under multiple sensory channels and with a moderate-to-high intensity. SS is a low invasive, not-dangerous, inexpensive, and simple to apply methodology, and for these reasons, it remains a potentially attractive rehabilitative method (Abbate and Mazzucchi, 2011). However, the theoretical basis of SS has not been clearly formulated in the past, and the method is grounded on general assumptions derived from valid, but out-of-date research findings (i.e., enriched environment as a prevention of sensory deprivation and promotion of synaptic re-innervation and arousal). In addition up until now there is no reliable evidence to support, or rule out, the effectiveness of SS in DOC patients (Lombardi et al., 2002; Lancioni et al., 2010). Thus, even though attractive, SS standard method seems to need a renovation.
Recently a large body of work has improved our knowledge about possible residual cognitive functioning of DOC patients. In particular, neurophysiologic and functional brain imaging studies consistently showed that a subset of DOC patients are able to produce some covert responses (e.g., hand movements), despite the lack of any overt behavioral manifestation (Bekinschtein et al., 2008; Cruse et al., 2012), suggesting a preservation of islands of high-order cognitive functioning (e.g., speech processing, mental imagery, etc.) (Schiff et al., 2002; Owen et al., 2006; Coleman et al., 2007; Owen and Coleman, 2008; Monti et al., 2010). Furthermore, consciousness mechanisms have been recently associated to new notions as distributed information (Tononi, 2004), interacting cortical areas and brain connectivity (Laureys, 2005; Rosanova et al., 2012). Consciousness is viewed as the capacity of a system to integrate information and it seems to depend on the brain's ability to support complex activity patterns distributed among interacting cortical areas (Tononi, 2004; Laureys, 2005; Dehaene and Changeux, 2011; Rosanova et al., 2012; Casali et al., 2013)1.
The aim of the present article is to evaluate if the main characteristics of SS method would still be appropriate, taking into account recent research findings and theoretical views elaborated on DOCs. In the case of inadequacies we suggest some possible modifications to the SS method which allow for improvements in light of new findings.
Rationale:
It is estimated that about 6 million people suffer from severe traumatic brain injury (TBI) each year (73 cases per 100,000 people). TBI may affect emotional, sensory-motor, cognitive, and psychological functions with a consequent worsening of both patient and his/her caregiver's quality of life. In recent years, technological innovations allowed the development of new, advanced sensory stimulation systems, such as Neurowave, to further stimulate residual cognitive abilities and, at the same time, evaluate residual cognition.
Patient concern:
An 69-year-old Italian man entered our neurorehabilitation unit with a diagnosis of minimally conscious state following severe TBI. He breathed spontaneously via tracheostomy and was fed via percutaneous gastrostomy. At the neurological examination, the patient showed severe tetraparesis as he showed fluctuating alertness and responsiveness to external stimuli and opened the eyes without stimulation.
Diagnosis:
Patient was affected by subarachnoid hemorrhage and frontotemporal bilateral hematoma, which were surgically treated with decompressive craniotomy and subsequent cranioplasty about 6 months before.
Interventions:
The patient underwent a neuropsychological and clinical evaluation before (T0) and after a conventional rehabilitation cycle (T1), and after a Neurowave emotional stimulation-supported rehabilitative cycle (T2).
Outcomes:
Following conventional rehabilitation (T1), the patient achieved a partial improvement in behavioral responsiveness; there was also a mild improvement in the caregiver's distress. Conversely, Neurowave emotional stimulation session determined (at T2) a significant improvement of the patient's behavioral responsiveness, cognition, and in the caregiver's distress. The P300 recording in response to the NES showed a significant change of P300 magnitude and latency.
Discussion:
Our data suggest that emotional-integrated sensory stimulation using adequate visual stimuli represents a beneficial, complementary rehabilitative treatment for patients in minimally conscious state following a severe TBI. This may occur because stimuli with emotional salience can provide a reliable motivational resource to stimulate motor and cognitive recovery following severe TBI.
Es gibt eine Vielzahl an sinnvollen und auch nachgewiesen wirksamen therapeutischen Maßnahmen bei Patienten im Wachkoma. Aufgrund der hohen Komplexität des Krankheitsbildes gibt es natürlich nicht „die Therapie“ des Wachkomas, die dazu führt, dass innerhalb kürzester Zeit der Patient völlig wiederhergestellt ist, so wie eine Antibiotikatherapie bei einer bakteriellen Lungenentzündung. Was immer wir tun, es muss uns klar sein, dass wir mit schwerstkranken und schwerstbehinderten Menschen und oft auch sehr instabilen Situationen konfrontiert sind. Oft ist schon ein kleiner Schritt in Richtung Stabilität und vielleicht in Richtung einer ersten oder weiteren Remission ein großer Gewinn. Was immer wir tun, muss gut überlegt und in einem Gesamtkontext beurteilt werden. Sowohl therapeutischer Nihilismus als auch reiner Aktionismus sind abzulehnen. Das Kapitel zeigt eine Vielzahl an Möglichkeiten auf, die, gezielt und konsequent, aber auch kritisch eingesetzt, zu einer Stabilisierung und positiven Entwicklung beitragen können.
A significant number of critically ill neurological and neurosurgical patients are still managed in the medical or surgical ICU by non-neurointensivists, who have a hard time appreciating the delicate needs of these patients. This dynamic guide reviews current topics facing neurocritical care providers in a straight-forward, structured, and practical way. Providing clear summaries in the management of neuro critical care conditions, this text allows for accessible, highly structured, and focused protocols for the assessment, day-to-day management, and treatment of critically ill patients in various ICU settings. This comprehensive, thorough guide to the management and treatment of neurologic and neurosurgical patients, is an excellent companion for trainees preparing for the Neurovascular Boards, Neurologists, Neurosurgeons and critical care physicians, alike. Designed by leaders in their field, this thorough guide presents practical, state-of-the-art suggestions for physicians, worldwide.
With the development of modern international medicine, the subject of disorders of consciousness (DOCs) has begun to be raised in mainland China. Much progress has been made to date in several specialties related to the management of chronic DOC patients in China. In this article, we briefly review the present status of DOC studies in China, specifically concerning diagnosis, prognosis, therapy, and rehabilitation. The development of DOC-related scientific organizations and activities in China are introduced. Some weaknesses that need improvement are also noted. The current program provides a good foundation for future development.
Diagnosis, prognosis and differentiation from the minimally conscious state (MCS) still rest on the observation of established clinical indicators of responsiveness . However, a systematic correlation has been documented between clinical responsiveness in VS/UWS and the sympathetic/parasympathetic functional balance measured by the Heart Rate Variability. Were treated 12 subjects. Six subjects underwent conventional rehabilitation sessions only when their HRV descriptors nuLF and peakLF were in the ranges with highest probability of response identified in previous studies, and six control subjects were treated without HRV monitoring. Improvement was greater in HRV monitored subjects: CRS-r scores were higher than in controls from the third week and the WHIM scores from the fourth week to the end of treatment. Systematic research could provide functional criteria to select each subject's optimal time windows of the day for treatment and possibly improve the efficacy of neurorehabilitation in the disorders of consciousness.
Unconscious patients after brain injury may survive for days or months and often experience decreased quality of life. To facilitate the recovery process and to prevent sensory deprivation after brain injury, sensory stimulation program (SSP) beginning in the early stages of recovery can be beneficial. This quasi-experimental study examined the effect of an SSP on recovery in unconscious patients after traumatic brain injury. Unconscious patients were divided into control and experimental groups. SSP was directed to five sensory modalities including tactile, gustatory, olfactory, auditory, and visual. Response to stimulation was assessed using the modified Sensory Modality Assessment and Rehabilitation Technique score and the Glasgow Coma Scale score. SSP was initiated 6.65 ± 2.35 days after injury in the control group and 6.8 ± 2.48 days for the experimental group. The results showed that mean modified Sensory Modality Assessment and Rehabilitation Technique scores after commencing the SSP in the experimental group were significantly higher than those in the control group (14.76 ± 2.33 vs. 8.72 ± 1.52, respectively, p < .05). Mean Glasgow Coma Scale scores after commencing the SSP in the experimental group were significantly higher than those in the control group (10.45 ± 1.82 vs. 5.9 ± 1.77, respectively, p < .05). The results indicated that the SSP can enhance brain recovery in traumatic brain-injured patients.
There is growing evidence that sensory deprivation is associated with crossmodal neuroplastic changes in the brain. After visual or auditory deprivation, brain areas that are normally associated with the lost sense are recruited by spared sensory modalities. These changes underlie adaptive and compensatory behaviours in blind and deaf individuals. Although there are differences between these populations owing to the nature of the deprived sensory modality, there seem to be common principles regarding how the brain copes with sensory loss and the factors that influence neuroplastic changes. Here, we discuss crossmodal neuroplasticity with regards to behavioural adaptation after sensory deprivation and highlight the possibility of maladaptive consequences within the context of rehabilitation.
The aim of the present study was to explore the concurrent validity, inter-rater agreement and diagnostic sensitivity of a French adaptation of the Coma Recovery Scale-Revised (CRS-R) as compared to other coma scales such as the Glasgow Coma Scale (GCS), the Full Outline of UnResponsiveness scale (FOUR) and the Wessex Head Injury Matrix (WHIM).
Multi-centric prospective study.
To test concurrent validity and diagnostic sensitivity, the four behavioural scales were administered in a randomized order in 77 vegetative and minimally conscious patients. Twenty-four clinicians with different professional backgrounds, levels of expertise and CRS-R experience were recruited to assess inter-rater agreement.
Good concurrent validity was obtained between the CRS-R and the three other standardized behavioural scales. Inter-rater reliability for the CRS-R total score and sub-scores was good, indicating that the scale yields reproducible findings across examiners and does not appear to be systematically biased by profession, level of expertise or CRS-R experience. Finally, the CRS-R demonstrated a significantly higher sensitivity to detect MCS patients, as compared to the GCS, the FOUR and the WHIM.
The results show that the French version of the CRS-R is a valid and sensitive scale which can be used in severely brain damaged patients by all members of the medical staff.
In view of the difficulties in finding control groups in sensory stimulation research, a single case methodology was explored. A pilot study was conducted on six comatose CHI patients in a neurosurgical intensive care unit. Each patient was given alternating weeks of directed multisensory stimulation (SDS) and non-directed stimulation (NDS) for half an hour a day in an ABAB single subject design. Eye movement, motor and vocal response to stimulation were recorded using the Sensory Stimulation Assessment Measure (Rader Scale). Comparisons of eye movement and motor responses on the Rader Scale appeared to indicate a greater degree of responsiveness to the SDS as compared with the NDS treatment. Overall improvement levels on the GCS, Rancho Scale and Western Neurosensory Stimulation Profile are discussed. The results are interpreted as indicative of the potential value of using single case methodology in this population, and future research directions are also discussed.
We used diffusion tensor imaging (DTI) to study 2 patients with traumatic brain injury. The first patient recovered reliable expressive language after 19 years in a minimally conscious state (MCS); the second had remained in MCS for 6 years. Comparison of white matter integrity in the patients and 20 normal subjects using histograms of apparent diffusion constants and diffusion anisotropy identified widespread altered diffusivity and decreased anisotropy in the damaged white matter. These findings remained unchanged over an 18-month interval between 2 studies in the first patient. In addition, in this patient, we identified large, bilateral regions of posterior white matter with significantly increased anisotropy that reduced over 18 months. In contrast, notable increases in anisotropy within the midline cerebellar white matter in the second study correlated with marked clinical improvements in motor functions. This finding was further correlated with an increase in resting metabolism measured by PET in this subregion. Aberrant white matter structures were evident in the second patient's DTI images but were not clinically correlated. We propose that axonal regrowth may underlie these findings and provide a biological mechanism for late recovery. Our results are discussed in the context of recent experimental studies that support this inference.
Behavioural, cellular and molecular studies have revealed significant effects of enriched environments on rodents and other species, and provided new insights into mechanisms of experience-dependent plasticity, including adult neurogenesis and synaptic plasticity. The demonstration that the onset and progression of Huntington's disease in transgenic mice is delayed by environmental enrichment has emphasized the importance of understanding both genetic and environmental factors in nervous system disorders, including those with Mendelian inheritance patterns. A range of rodent models of other brain disorders, including Alzheimer's disease and Parkinson's disease, fragile X and Down syndrome, as well as various forms of brain injury, have now been compared under enriched and standard housing conditions. Here, we review these findings on the environmental modulators of pathogenesis and gene-environment interactions in CNS disorders, and discuss their therapeutic implications.
The purpose of this study was to evaluate the possible therapeutic benefits of intense multi-sensory stimulation (IMS) in the management of profound coma. Two hundred hospitalised patients with Glasgow Coma Scale (GCS) scores of 6 or less recorded on admission and 1 week later, were included in the IMS treatment programme. Twenty-seven patients were seen within the first month following injury and the onset of coma. The remaining 173 patients were first seen on average 6 months post-onset, with the longest period of coma extending to 2 years prior to IMS. All had a “hopeless” prognosis recorded on their charts and all were reported as being in a persistent vegetative state (PVS). Outcome results are compared with 33 patients (controls) of similar age, sex, and aetiological and GCS distribution who did not receive IMS; 34.5% of the IMS group made a moderate to good recovery based on Glasgow Outcome Scores (GOS), 9% have remained in PVS, 56.5% are still severely disabled with marked psychomotor deficits, but are out of coma and some are continuing to show progress. A total of 91% are out of coma; 33 patients in the control group (100%) remain in coma. The results of this study support earlier observations that the worst prognostic criteria do not apply uniformly to the patient in either acute or chronic coma, and that the outcome in both conditions can be markedly influenced by IMS.
Adult primary sensory cortex is not hard wired, but adapts to sensory experience. The cellular basis for cortical plasticity involves a combination of functional and structural changes in cortical neurons and the connections between them. Functional changes such as synaptic strengthening have been the focus of many investigations. However, structural modifications to the connections between neurons play an important role in cortical plasticity. In this review, the authors focus on structural remodeling that leads to rewiring of cortical circuits. Recent work has identified axonal remodeling, growth of new dendritic spines, and synapse turnover as important structural mechanisms for experience-dependent plasticity in mature cortex. These findings have begun to unravel how rewiring occurs in adult neocortex and offer new insights into the cellular mechanisms for learning and memory.
Environmental enrichment (EE) has long been exploited to investigate the influence of the environment on brain structure and function. Robust morphological and functional effects elicited by EE at the neuronal level have been reported to be accompanied by improvements in cognitive performance. Recently, EE has been shown to accelerate the development of the visual system and to enhance visual-cortex plasticity in adulthood. These new findings highlight the potential of EE as a promising non-invasive strategy to ameliorate deficits in the maturation of the nervous system and to promote recovery of normal sensory functions in pathological conditions affecting the adult brain.
The practice of coma arousal and sensory stimulation is becoming the focus of heated debate. There is no theory on which patients may benefit, at what time in their recovery, or how the 'arousal' or 'stimulation' procedures should be applied. This paper considers some of the information processing mechanisms that are important mediators of arousal and awareness, pointing to some of the weaknesses in current practices and suggesting alternative approaches. Recommendations for a conceptual model of sensory stimulation are given that might provide a more scientific perspective to those who use such methods.
Patients diagnosed as being in prolonged coma (vegetative state) in this hospital are routinely treated according to a sensory stimulation protocol. This paper reports an evaluation of the efficacy of this procedure using the comparison of behavioural measures taken immediately prior to and post-stimulation. Four single cases produced significant behavioural changes suggesting increased arousal as a result of stimulation. The results and implications for further evaluation studies are discussed.
This study investigated the effects of different levels of brain injury rehabilitation intensity on length of stay in two hospital-based coma and acute rehabilitation populations. In two hospitals, in separate areas of the USA, rehabilitation intensity was increased from 5 h per day to 8 h per day, 7 days per week. Patients were studied retrospectively both before and after the change in intensity. There were no significant differences among subjects in age, education, time since injury or level of functioning on admission either across hospitals or from pre- to post-change-in-intensity. Results show that the length of stay significantly decreased 31% for both coma and acute groups in both hospitals. Implications of these findings for clinical treatment and social policy are discussed.
The rehabilitation outcome of patients with severe traumatic brain injury (TBI) is well documented and is highly correlated to the neurobehavioural sequelae of CNS damage. However, many of these patients suffer from polytrauma involving systems other than the CNS and to systems involved in acquisition of external information. In the present series of 328 patients with severe TBI, 58% had associated trauma, mostly in the skeletal system. The presence of one single associated trauma had no additional effect on rehabilitation as evaluated by actual work placement. In contrast, multiple lesions were liked with a less favourable outcome, probably due to a greater severity of the initial CNS damage. Disturbances in the various information-acquiring systems (e.g. disturbances in eye movements, visual field defects and severe bilateral auditory deficits) were associated with poor outcome. Presence of peri-articular new bone formation and communicating hydrocephalus, usually associated with prolonged periods of unconsciousness, indicated a poor rehabilitation outcome as well.
This descriptive study was a pilot effort to determine the effect of specific sensory input on the cortical activity of a selected population of young adults with a closed head injury. The specific research questions were (1) Does the comatose patient demonstrate a response on an electroencephalogram (EEG) to a specific auditory stimulus? (2) Does the comatose patient demonstrate other types of responses to a specific auditory stimulus? The subjects were three male and two female young adults 15 to 29 years of age who had a closed head injury as the result of an automobile accident. A similarity in depth of coma was established by using the Glasgow Coma Scale. Cortical activity was recorded by EEG at the same time that auditory stimulation was introduced to the subject. Data obtained by observation during the period of EEG recording were also included by an additional measure of the subject's response to stimulation. The findings indicate that persons in a coma do respond to auditory stimulation. The responses were varied in this small sample, but some type of response did occur. Two patients demonstrated a response on EEG and the other responded by eye opening or extremity movement. The EEG alone does not appear to be useful as a measure of response to auditory stimulus. Further work needs to be done to determine what other methods measure the response of comatose patients to auditory stimulation.
This study reports on the efficacy of a 'coma arousal procedure'. This procedure involved a programme of vigorous sensory stimulation administered to comatose patients by relatives using Comakits. An experimental group of 12 severely head-injured patients received the coma arousal procedure while a matched control group did not. Total duration of coma and weekly Glasgow Coma Scale Scores were recorded for the two groups. Results indicate that the total duration of coma was significantly shorter and that coma lightened more rapidly for the experimental group.
The Western Neuro Sensory Stimulation Profile (WNSSP) was developed to assess cognitive function in severely impaired head-injured adults (Rancho levels II-V) and to monitor and predict change in slow-to-recover patients. Slow-to-recover patients are those who remain at Rancho levels II and III for extended periods of time and are candidates for sensory stimulation programs. Although sensory stimulation is considered beneficial, its utility has not been documented, partly because of the absence of formal measurement tools. The WNSSP consists of 32 items which assess patients' arousal/attention, expressive communication, and response to auditory, visual, tactile, and olfactory stimulation. It was administered to 57 patients with a mean age of 29 years at a mean time of eight months after injury. Statistical analyses indicate the WNSSP to be a reliable, valid measure of cognitive function. WNSSP means differ at each Rancho level, and ranges of scores at each level are sufficiently broad to demonstrate improvement within as well as across cognitive levels. Subjects who later improved performed significantly better on initial testing than did those who did not improve, suggesting prognostic ability of the WNSSP. Our data support other investigations which emphasize that some slow-to-recover patients experience significant improvement. The WNSSP can be a useful tool for studying the recovery process and evaluating treatment programs for slow-to-recover patients.
A clinical scale has been evolved for assessing the depth and duration of impaired consciousness and coma. Three aspects of behaviour are independently measured—motor responsiveness, verbal performance, and eye opening. These can be evaluated consistently by doctors and nurses and recorded on a simple chart which has proved practical both in a neurosurgical unit and in a general hospital. The scale facilitates consultations between general and special units in cases of recent brain damage, and is useful also in defining the duration of prolonged coma.
We evaluated the states of consciousness of seven persons who had sustained a severe head injury, and describe the behavioural manifestations associated with four treatment strategies. The subjects were between the ages of 19 and 55 and were recruited from both acute and long-term care facilities; all were in an altered state of consciousness. The severity of the injury was measured by time in coma, the scores on the Glasgow Coma Scale [1] and the Coma Near Coma Scale [2]. Structured interventions consisted of visual, auditory, olfactory, gustatory and tactile stimulation; behaviour was measured using the Disability Rating Scale [3, 4] and a portion of the Levels of Cognitive Functioning Scale [5]. Sensory-motor indications were recorded using a questionnaire developed by Freeman [6] and a quality-of-life instrument, developed for use with individuals having multiple disabilities [7], was adapted for the purpose of this study. Our results suggest that the use of structured interventions in the first 24 months following severe head injury is associated with a trend towards improved auditory and visual skills performance, manual performance, swallowing and language. Whereas initially no subject had any form of verbalization, by the final evaluation five subjects had some form of communication, either verbal or non-verbal.
We investigated the efficacy of applying a programme of multisensory stimulation to patients with severe diffuse traumatic brain injury, during their admission to a tertiary neurosurgical intensive care unit. We attempted to determine the nature and extent of any physiological or biochemical changes occurring as a result of the multisensory stimulation in the initial period of their comatose state. The findings were inconclusive with no significant treatment effect demonstrated. © 1993 Informa UK Ltd All rights reserved: reproduction in whole or part not permitted.
The purposes of this case study were (1) to determine whether a comatose patient responded differentially to four types of auditory stimuli--voices of family members and friends, classical music, popular music, and nature sounds--and (2) to determine what physiological measures and behavioral observations best captured changes in responsiveness. The patient participated in 28 sessions that were videotaped for later behavioral analysis. During all sessions, measures were taken of pulse rate, respiration rate, and skin resistance. Visual inspection of the data and Auto Regressive Integrated Moving Average (ARIMA) analyses revealed greater increases in responsiveness with the presentation of taped voices of family and friends than with other types of taped stimuli. Behavioral observations of body movements and measures of pulse rate were superior to observations of facial expressions and measures of respiration rate and galvanic skin response in revealing changes in responsiveness. Despite extreme diversity among comatose persons, the research findings support the contention that responses to various auditory stimuli differ and are measurable with relatively simple behavioral and physiological observations.
This paper reports on a meta-analysis of behavioural data gathered using single case research methodology, while evaluating the immediate effects of a treatment (sensory stimulation) on 24 individuals diagnosed as being in vegetative state following trauma. The data derived from time sampling have been used to compile measures of behavioural change in response to environmental events, which are referred to as arousal profiles. In addition to this, interviews were conducted regularly to elicit structured observations from the nursing staff concerning behavioural changes that they had observed. The subjects were divided into two groups according to whether they had emerged from vegetative state or not at the time the meta-analysis commenced. Statistically significant differences were found between the outcome groups in terms of modal arousal profile characteristics; one profile type was characteristic only of those that emerged. The two groups could also be differentiated by the mean recovery curves derived from the interview data. Behavioural differences between the outcome groups have been found which are detectable while the patients are in vegetative state. These findings have prognostic potential.
An early and consistent administration of the correct rehabilitation programme is of crucial importance for the restoration and improvement of cerebral function, as well as social reintegration. This has led to the development of a multimodal onset stimulation therapy (MEOS), which the neurosurgical intensive care unit administers during an early phase of rehabilitation to patients who have been in a coma for more than 48 hours after trauma. This study, which was carried out over a period of 2 years, focuses on 89 patients aged 16-65 years suffering from severe brain injury. Sixteen of these (age mean: 43.6 years) fulfil the criteria required to start the MEOS. The authors were able to identify significant changes in two of the patients' vegetative parameters (viz. heart and respiratory frequencies), even in cases of deep coma (GCS 3-4). The most significant changes were caused by tactile and acoustic stimulation. Standardized behavioural assessment turned out to be particularly advisable in cases of medium coma. Here, too, a stimulation of the tactile and acoustic senses resulted mainly in head and eye movements.
To assess the effectiveness of sensory stimulation programmes in patients in coma or vegetative state.
Systematic review of randomized control trials (RCT) and nonrandomized controlled clinical trials (CCT) comparing any type of stimulation programmes with standard rehabilitation in patients in coma or vegetative state. The Injuries Group specialized register, the Cochrane Controlled trial register, EMBASE, MEDLINE, CINAHL, PSYCHLIT from 1966 to January 2002 were searched without language restriction. Reference lists of articles were scanned and experts in the area contacted to find other relevant studies. Abstracts and papers found were initially screened by one reviewer. Three reviewers independently identified relevant studies, extracted data and assessed study quality, resolving disagreement by consensus.
Duration of unconsciousness (including coma and vegetative state) defined as the time between trauma and objective recovery of the ability to respond to verbal commands; level of consciousness, as measured by the Glasgow Coma Scale (GCS); level of cognitive functioning (LCF); functional outcomes, as measured by Glasgow Outcome Scale (GOS) or by Disability Rating Scale; negative effects (e.g. increased intracranial pressure).
Three studies (one RCT and two CCTs) with 68 traumatic brain-injured patients in total, most of whom were road accident victims, met the inclusion criteria. The overall methodological quality was poor and studies differed widely in terms of study design and conduct. Moreover, due to the diversity in reporting of outcome measures, a quantitative metanalysis was not possible. None of the three studies provided useful and valid results on outcomes of clinical relevance for coma patients.
This systematic review indicates that there is no reliable evidence to support the effectiveness of multisensory stimulation programmes in patients in coma or the vegetative state.
The purpose of this study was to examine whether positive changes in consciousness level after applying a sensory stimulation programme exceed natural recovery.
• A single experimental group interrupted time series design was used.
• Subjects were brain‐injured patients who were hospitalized at a university hospital in South Korea.
• The sensory stimulation programme was composed of auditory, visual, olfactory, gustatory, tactile and physical stimulation. Levels of consciousness were evaluated using the Glasgow Coma Scale.
• The intervention was carried out twice, first for 4 weeks, then a recession period was allowed for 4 weeks, and immediately after this the second intervention was implemented for 4 weeks.
• Results showed significant alterations in consciousness levels 2 weeks after starting intervention 1. This effect increased gradually and was maintained for 3–4 weeks. However, consciousness levels began to decrease 2 weeks after terminating intervention 1 and this decrement continued until starting intervention 2. The pattern of improvement of intervention 1 could be represented as a gradual onset and temporary duration model.
• At the beginning of intervention 2, consciousness levels were maintained at a low level. However, they began to increase again after 2 weeks and this increment continued even after terminating intervention 2. Therefore, the effect of intervention 2 could be represented as a gradual onset and permanent duration model.
• These results suggest that an intervention programme should be applied for more than 1 month to achieve a permanent effect on consciousness levels and that at least 2 weeks are required for any significant effect.
Nursing therapies promote recovery following severe traumatic brain injury (TBI). However, the type and dose of treatment needed to stimulate functional plasticity have not been determined. In this quasi-experimental study, the effects of a structured auditory sensory stimulation program (SSP) were examined in 12 male patients, 17-55 years old, with severe TBI. SSP was initiated 3 days after injury and continued for 7 days. Recovery was measured by comparing baseline Glasgow Coma Scale (GCS), Sensory Stimulation Assessment Measure (SSAM), Ranchos Los Amigos Level of Cognitive Functioning Scale (RLA), and Disability Rating Scale (DRS) scores to ending scores between those who received SSP and those who did not. For the intervention group a positive recovery of function trajectory was found for mean GCS, and there was a greater improvement in GCS and RLA scores between baseline and at discharge testing periods. DRS and SSAM scores at baseline and at discharge were significantly different. SSP did not affect hemodynamic or cerebral dynamic status. Early and repeated exposure to an SSP may promote arousal from severe TBI without adversely influencing cerebral dynamic status.
To determine the measurement properties and diagnostic utility of the JFK Coma Recovery Scale-Revised (CRS-R).
Analysis of interrater and test-retest reliability, internal consistency, concurrent validity, and diagnostic accuracy.
Acute inpatient brain injury rehabilitation hospital.
Convenience sample of 80 patients with severe acquired brain injury admitted to an inpatient Coma Intervention Program with a diagnosis of either vegetative state (VS) or minimally conscious state (MCS).
Not applicable.
The CRS-R, the JFK Coma Recovery Scale (CRS), and the Disability Rating Scale (DRS).
Interrater and test-retest reliability were high for CRS-R total scores. Subscale analysis showed moderate to high interrater and test-retest agreement although systematic differences in scoring were noted on the visual and oromotor/verbal subscales. CRS-R total scores correlated significantly with total scores on the CRS and DRS indicating acceptable concurrent validity. The CRS-R was able to distinguish 10 patients in an MCS who were otherwise misclassified as in a VS by the DRS.
The CRS-R can be administered reliably by trained examiners and repeated measurements yield stable estimates of patient status. CRS-R subscale scores demonstrated good agreement across raters and ratings but should be used cautiously because some scores were underrepresented in the current study. The CRS-R appears capable of differentiating patients in an MCS from those in a VS.
Neural plasticity represents a crucial mechanism of the human brain to adapt to environmental changes in the developing and adult human central nervous system. This property of the central nervous system contributes to learning and functional recovery from neurological diseases such as stroke. Novel interventional approaches have been proposed and are under investigation to modulate neural plasticity, enhance it when it plays an adaptive role and downregulate it when it is considered maladaptive.
One of the purposes of research in neurorehabilitation has been to develop interventional approaches to enhance the beneficial effects of training. Procedures like cortical stimulation, administration of central nervous system active drugs and modulation of afferent input have been evaluated as drivers of neural plasticity in healthy subjects and in small groups of patients with stroke. So far, these studies have shown promising results and translation into the clinic is under investigation.
Cortical stimulation and purposeful changes in afferent input that modulate neural plasticity impact on behavioral markers of performance, learning and functional recovery and represent promising tools in neurorehabilitation.
Intensity of rehabilitation and length of stayView Article
- Wf Blackerly
Enriched and improverished environments: effects on brain and behaviour
- M Renner
- M Rosenzweig