Coma Stimulation Techniques

Coma stimulation techniques for Physiotherapists in handling comatose patients

1. COMA STIMULATION

2. WHAT IS COMA Patient’s eyes do not open either spontaneously or to external stimuli Does not follow command Does not mouth or speak recognizable words Does not demonstrate intentional movement ( may show reflexive movement such as posturing, withdrawal from pain or involuntary smiling) Patient cannot sustain visual pursuits through a 45° arc in any direction when the eyes are held open manually. (American Congress of Rehabilitation Medicine, 1995) Coma is a profound state of unconsciousness .

3. COMA STIMULATION Coma stimulation programme is an approach based on stimulating the unconscious person’s senses of hearing, touch, smell, taste and vision individually in order to help their recovery. Types: Unimodal/Multimodal Techniques: Visual/Auditory/Olfactory/Gustatory/Cutaneous/Kinesthetic.

4. THEORIES OF COMA STIMULATION Spare capacity and reorganization: Activation of Non- Active/Spare/Dormant areas The redundancy theory: Ability to duplicate neuronal pathways The response at a cellular level theory: Collateral sprouting to attempt rewiring the system. The environmental effects theory

5. PRINCIPLES Cardinal Rule - Do not harm the patient Check the resting vitals Stop immediately in case of ICP/CPP raise Control environmental distractions Organise the stimuli Provide distinct and well differentiated stimuli Allow extra time for the patient to respond Meaningful stimuli Verbally reinforce responses Try stimulating all the senses Identify stimuli which the patient responds to Include family participation Garret, Muehhng , Morrow and Riggs (1990)

6. CRITERIA FOR ELIGIBLE PATIENTS Patients with acute hemorrhage, diffuse axonal injury, hypoxia or stroke GCS score less than 10 RLA score of I, II, III Stable vitals ICP of less than 15 mm hg for atleast a 24 hour period

7. COMA STIMULATION KIT

8. AUDITORY STIMULATION Loud noises e.g., banging two saucepans, ringing bell or rattle, blowing whistle, clapping hands, reading books, playing tape, TV, Radio Should to irregular to prevent habituation Talk to patient, call by patient’s name Speak slowly, no complex commands Regular stimulation

9. VISUAL STIMULATION Flashing Lights, Strobes, Flash cards (Words or pictures printed on contrast background), photographs, TV Reinforce with verbal instruction

10. OLFACTORY STIMULATION Use after shave, cologne, perfume, shampoo, eucalyptus oil, patient favorite coffee or tea Avoid vinegar and ammonia Provide the stimuli for no more than 10 seconds Use garlic and mustard as noxious stimuli

11. ORAL STIMULATION Use a sponge tipped or glycerin swab or a soft tooth brush to reduce hypersensitivity and abnormal oral/facial reflexes. Provide stimulation to the lips and area around the mouth. Pursing lips, closing mouth or pulling away from the stimulus are the indicators of right stimulation.

12. TACTILE STIMULATION May be facilitatory or inhibitory. E.g., Pain and light touch to skin produces inhibitory response/ Touch, pressure, slow stroking of the spine produces facilitatory response Avoid unpleasant stimuli like pin prick, Avoid ice to face or body as it may trigger sympathetic nervous system Use variety of textures/ variet of temperatures (warm or cold clothes/ metal spoons dipped for 30 secs in hot or cold water) Varying pressure on muscle belly and tendon, rubbing sternum, pressing nail bed etc.,

13. GUSTATORY STIMULATION Provide taste stimulation, unless patient is prone to aspiration. Cotton swab dipped in sweet, salty or sour solution Avoid excess sweet as it induces more salivation. Facial grimacing is an indicator that the taste sensation is working

14. KINESTHETIC/PROPICEPTIVE/ VESTIBULAR STIMULATION Slow change in position tend to inhibit/ Faster movements facilitate arousal Mobility activities promote body and positional awareness Using Tilt table, Rocking chairs, frequent position changes in bed Avoid spinning movements may trigger seizures Avoid mechanical inputs like sudden raising and lowering of bed

15. SESSIONS Frequency: Start at an hour per day to increase gradually to an intense 6 – 8 hours per day. 10 to 15 minute sessions to 45 to 90 minutes sessions as patient improves. Wait for 1 to 2 minutes for response to occur Adequate rest in between sessions is recommended

16. RIGHT MEDIAN NERVE STIMULATION [RMNS] Large cortical representation Peripheral port Spinoreticular component of median nerve pathway RAS & Limbic system Activates projections between thalamus and cortex Possibly silent or injured synapses are transformed into functional ones by neurotrophic factors Increased cerebral blood flow and enhancement of neurotransmitter metabolism Lei J, et al. J Neurotrauma 2015;32:1584–89

17. RMNS - PARAMETERS High Frequency biphasic Electrical Stimulation Asymmetric biphasic pluses at an amplitude of 15–20 mA (as tolerated) Pulse width of 300 μs at 40 Hz ON for 20 s and OFF for 40 s 8 hours per day Wu X, Zhang C et al., Right median nerve electrical stimulation for acute traumatic coma (the Asia Coma Electrical Stimulation trial): study protocol for a randomised controlled trial. Trials. 2017;18(1):311.

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