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Coma Stimulation

PHTH 667.01 Neuromuscular

Colin Walthour

on 10 April 2013

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Transcript of Coma Stimulation

Coma Stimulation PHTH Neuromuscular 1
By: Colin Wathour, Justin Schomaeker,
Nate Etler, Kyle Shroll, & Stephen O'Rear Coma: Refers to a state of complete unresponsiveness in which the eyes remain continuously closed!
Basically, any comatose patient in a stable medical condition is considered a suitable subject for a coma arousal program. Underlying Principles/History Contraindications; Indications: If coma stimulation is desired it should begin immediately
Little research about duration, frequency and intensity
Some think that stimulation could prolong the coma and
others believe it could reduce the length
Lack of evidence When to use Coma Stimulation/Technique/Protocols Emerging Research Recomendations Considered a treatment option, not a standard

It remains unknown what is the best duration/intensity/or frequency to administer such sensory stimulation.

There has been some research literature proposing that such stimulation helps acutely brain-injured people recover from coma more rapidly. Start coma stimulation early in rehabilitation progression! May improve the quantity and quality of responses toward purposeful activity
May provide opportunities for the patient to respond to the environment in an adaptive way
May heighten the patients' responses to sensory stimuli and eventually channel them into meaningful activity Do no harm!
Before starting any stimulation, check resting vital signs (HR, BP, and Respiratory Rate). Avoid any sensory stimulation if you notice an increased ICP!
Avoid any distraction when providing sensory input.
Be sure to provide distinct and well differentiated stimuli. Indications:
Visual Stimulation
Auditory Stimulation
Touch Stimulation
Movement Stimulation
Position Stimulation
Smell Stimulation
Taste & Oral Stimulation Assessment of Localization to Auditory Stimulation in Post-Comatose States: Use the Patient's Own Name Did the auditory stimulus influence the localization of that sound in patients recovering from a coma?
Used patients own name, intrinsically meaningful and personally significant
Stimuli such as a name are so "potent" that they can capture attention and bring stimulus into view
Cocktail- party phenomenon continued: Bell and Name used for auditory stimuli
Matched for intensity and duration, randomly presented continued: Localization of sound depends on stimulus
Name used since infancy, sound pattern recognizable
Perception of name leaves way after perception of time and place in pt's with dementia
General anesthesia: react to name first before pain or noise
Duration and degree of movement not taken into consideration TAKE HOME POINTS References: 1. Cheng L, Gosseries O, Ying L. Assessment of localization to auditory stimulation in post-comatose states: use the patient's own name. BMC Neurol. 2013 Mar 18;13:27. More Evidence: "Change in Cerebral Perfusion of Patients With Coma After Treatment With Right Median Nerve Stimulation and Hypberbaric Oxygen." Median Nerve Stimulation:
Increased Cerebral Blood Flow
Improved Electroencephalography
Improved Glasgow Coma Scale scores
Significant or Even Complete Arousal of Conciousness Hyperbaric Oxygen:
Minimizing Damage Associated with Brain Injury
Increasing Perfusion of O2 to the Brain 2. Liu J, Lee J, Tyan Y, Liu C, Lin T. Change in Cerebral Perfusion of Patients With Coma After Treatment With Right Median Nerve Stimulation and Hyperbaric Oxygen. Neuromodulation [serial online]. November 2008;11(4):296-301. Available from: Academic Search Complete, Ipswich, MA. Accessed April 9, 2013. Treatment Protocol: 41 eligible patient were admitted to the institution.
11 cases of Severe Stroke
5 cases of Severe Hypoxia
25 cases of Brain Trauma Subject Pool: Types of Stimulation Available: Discussion: Results: Decison-makers were offered the option of MNS for six weeks or (MNS + HBO) for six weeks
Continued for 3 months if the patient responded to treatment Of 41 patients, 14 received MNS and 27 received MNS + HBO Pre and post-treatment SPECT scans showed increased cerebral perfusion in 29 patients, with perfusion unchanged in 9 patients and decreased in 3 patients

Analysis indicated that MNS + HBO was significantly related to increased cerebral perfusion compared with MNS alone The combination of MNS + HBO is more likely to result in improved cerebral perfusion than MNS alone!

Big Picture: Analysis suggests that patients with TBI and stroke are more likely to benefit from MNS + HBO When looking at the GCS, patients with TBI were significantly more likely to have improvement than patients with other etiologies. Effect of stimulation in coma Randomized controlled trial
Non-traumatic neurological insult; Study and control groups each with 30 children
Study received stimulation therapy
Control received no stimulation
Level of consciousness (LOC) assessed before and 2 weeks following stimulation therapy
Causes of coma within study
Pyogenic meningitis
Cerebral malaria
Tubercular meningitis
Fulminating hepatic failure
Majority of children were boys ages 1-5 years old Treatment was initiated shortly after the acute phase of injury and hospitalization!
MNS: Stimulation was applied at 300µsec asymmetric pulses at 35 Hz and 20 mA given intermittenly for 1 hours
HBO + MNS: Chamber was set at 100% oxygen, 2.5 ATA compression at 1psi/min, for 90 min in five sessions (total 30 sessions) per week starting when MNS began.
- This group received the same MNS treatment. Control Group
Through the 2 weeks, remained almost unchanged and did not show any significant improvement Early stimulus therapy,<5 days of onset, and
intermediate period had better improvements than those starting after 15 days of onset. AVPU scale
Awake and alert
Responds to voice
Responds to pain
Significantly improved in AVPU and GCS scale Studies limitations
Smaller sample size
Short duration
Not all stimulation was monitored Take Away
Start coma stimulation via six senses following patient's medical stability
Stimulation of senses increases progression to recovery Results 3. Karma D, Rawat AK. Effect of Stimulation in Coma. Indian Pediatr. 2006 Oct;43(10):856-60. Stimulation Used Visual Stimulation
light of torch
Bright colors
Familiar faces Auditory
Ring bells
Familiar voice Olfactory
Scented sticks
Spirit swab Gustatory
Sugar and salt solution
Orange juice Tactile
Massage with and without oil Kinesthetic stimulation
Rolling side to side
Change of posture
Full ROM in limbs 5 times per day every 2-3 hours
Family members educated Goals of Coma Stimulation: History: 1950’s: Institute for the Achievement of Human Potential (I.A.H.P.):
Stressed environmental sensory input, at frequency, intensity, and duration greater than those in the hospital setting, could enhance speed and degree of recovery from coma The Early 90's:
The use of sensory stimulation for coma and vegetative state gained popularity in western world, despite a lack of scientific evidence Present:
“Clinical research has shown mixed reviews over whether patients exposed to a differentiated bombardment of sensory information will recover qualitatively better or more quickly!" Late 1970's:

"In comatose patients, although problem is primarily cerebral, there is a condition of environmental deprivation that could lead to widespread impairment of intellectual and perceptual processes accompanied by changes in cerebral electrical activity”

-Edward Lewinn Cardinal Rule: As it Relates to ICP: 4. Oh H, Seo W. Sensory stimulation programme to improve recovery in comatose patients. J Clin Nurs. May 2003;12(3):394-404.

5. Yamamoto T, Katayama Y, Obuchi T, Kobayashi K, Oshima H, Fukaya C. Spinal Cord Stimulation for Treatment of Patients in the Minimally Conscious State. Neurol Med Chir. 2012 July; 52:475-481 "Sensory stimulation programme to improve
recovery in comatose patients." Prior to implementing the sensory stimulation program, consciousness levels were measured once a day for 4 weeks as baseline.
Glascow coma scale was used for assessment
The first intervention was provided twice a day, 5 days per week for 4-week periods
During the recession period (4 weeks), only ordinary medical treatment and nursing care were provided, and consciousness levels were measured.
Immediately after the recession period, the second intervention was implemented twice per day, and 5 days per week for 4 weeks. Specific types of stimulation were selected in accordance with patients’ past preferences thereby providing an individualized sensory program.
The intervention was given in the same order at the same time of day, with minimal background noise levels and other undesirable environmental stimulation Visual Stimulation Colored papers were used in addition to a light pen, faces of the patient’s family and pictures Auditory Stimulation
Administered by music, the voice of a family member, hand-clapping, a tuning fork and a ringing bell Olfactory Stimulation
Perfume, vinegar, orange and lemon Results :
Showed significant alterations in consciousness levels 2 weeks after starting intervention 1. This effect increased gradually and was maintained for 3–4 weeks
Consciousness levels began to decrease 2 weeks after terminating intervention 1 and this decrement continued until starting intervention 2 Results Cont.
At the beginning of intervention 2, consciousness levels were maintained at a low level.They began to increase again after 2 weeks and this increment continued even after terminating intervention 2.

The results suggest that an intervention program 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 * Very much dependent on PT's adeptness
and familiarity Research Evidence Spinal Cord Stimulation for Treatment of Patients in the Minimally Conscious State Really, anyone that is in a medically stable coma could be considered a candidate! Medically Unstable
BP, HR, Respiratory Rate, ICP *Always listen to the caregiver/
power of attorney Patient Population History Gustatory Stimulation
Sour, salty, sweet and hot sensations How they ran their study/research Some studies support Deep Brain Stimulation (DBS) to patients who are in a vegetative state;
but some studies support SCS on patients in a MCS.
This research article focuses more on SCS than DBS. So..... Tactile Stimulation
Touch, temperature and pain were applied separately 6 individuals had head injuries
3 patients had cerebrovascular accidents
1 patient had encephalomyelitis Patients were between a minimally conscious state (MCS)and a vegetative state.

MCS = inconsistent but clearly discernible behavioral evidence of consciousness, and can be distinguished from coma and VS by the presence of specific behavioral features not found in either of these conditions. Initial Status Even though the study deals with patients who are in between a vegetative state, MCS and not so much a coma; there is still some value in the study. Reminder for Justin:
5) PEPPERMINT Patients were given a electrode package via 18 gauge Toughy needle
into the subdural space
in the area of c2-c4
Also the patients had a implantable pulse generator placed under the anterior chest wall Connecting these two devices stimulus. Treatment parameters:
-5 minutes every 30 minutes during the day time.
-There was no real set length (long term) for the intervention, but some patients had it done for up to a year
-At an intensity that produced twitching in the UE (which is helpful in neuromuscular rehab...thanks agents and modalities class) Patient permission was obtained before engaging in the study. Results With SCS therapy, all 10 patients had neuromuscular benefits from twitching induced by SCS.

8 of the 10 patients had a significant increase in Cerebral Blood Flow (CBF) which we all know is crucial for healing and recovery.

Of those 8 individuals who were bed ridden and in a vegetative or MCS state for a long period of time; 5 of them were either able to use a wheelchair by themselves or walk by themselves.

Some patients were playing rhythm on a guitar and being able to manipulate all 6 planes of a rubix cube! These patients were doing SCS therapy for around a year. This is controversial because they might have just recovered from time alone. Negatives: There were only 10 patients ? The twitching was not self induced, although it was beneficial Invasive Procedure Long duration for treatment
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