Multimodal Sensory Stimulation Treatment for an Individual with Chronic & Severe TBI

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1 Multimodal Sensory Stimulation Treatment for an Individual with Chronic & Severe TBI Sakina S. Drummond & Melissa McDonough Southeast Missouri State University ASHA Convention, Chicago, IL 2008

2 Introduction: Sensory Stimulation Sensory stimulation is a common intervention method for patients in coma following traumatic brain injury (TBI). Sensory stimulation activates the limbic system to help generate goal-directed behaviors 1, 2. Emotion-provoking stimuli enhance amygdaloid activity to facilitate limbic system activitation 3, 4. Benefits from sensory stimulation are boosted if it is delivered by persons familiar to the comatose patient 5.

3 Multimodal Sensory Stimulation Sensory stimulation can be provided through different modalities: Auditory Tactile Gustatory Vestibular Visual Olfactory Kinesthetic Proprioceptive Simultaneus use of two or modalities are typically referred to as multimodal stimulation. Combined use of the following modalities have been the most efficacious 6, 7 : Tactile + auditory stimulation Visual + proprioceptive stimulation

4 Research Need Literature supporting sensory stimulation is restricted to individuals recovering from acute TBI 6, 8, 9, 10, 11. Approximately 14% of TBI patients remain in persisting vegetative state long after discharge from acute rehabilitation 7. There is no evidence on the delivery of sensory stimulation to chronic individuals with TBI. Systematic presentation of multimodal stimulation by persons familiar to the comatose individual remains unexamined.

5 Research Purpose & Design Influence of the following variables was determined: Controlled combinations of sensory stimuli Emotional ties to stimuli Stimulation delivery by familiar personnel A longitudinal, single-subject (ABA) design was used: Pre- and post-intervention assessment (A) phases Intervening delivery of multimodal stimulation (B) phase

6 Subject Description A 23 year old Caucasian male with severe TBI from a fall served as the subject. The onset of TBI was at age 17, five years prior to the study. Subject was a senior in high school at that time. Subject remains in vegetative state since the TBI. Subject currently resides in a nursing home. Subject s father (legal guardian) completed the institutionally approved Informed Consent Form.

7 Assessment Tools Three assessment protocols were used: Glasgow Coma Scale (GCS) 12 Ranchos Los Amigos (RLA) severity rating scale13, 14 Western Neurosensory Sensory Stimulation Protocol (WNSSP) 15 Each of these procedures was completed at two intervals: Prior to delivery of multimodal stimulation One week following intervention.

8 Intervention Stimuli Five modality pairs were used for stimulation: Auditory + tactile Auditory + thermal Auditory + visual Auditory + olfactory Auditory + gustatory Two sets of stimuli (familiar/pleasurable +unfamiliar/aversive) were selected for each modality pair, resulting in 10 total sets. Each stimulus pair was presented for at least 5 seconds. Each modality pair was presented in a consistent order. Two trials of each modality pair were presented in each session (refer to Table).

9 Table: Modality Pairs, their Presentation Order & Respective Stimuli for Each Trial Modality Pair Auditory-tactile stimulation Auditory-thermal stimulation Auditory-visual stimulation Auditory-olfactory stimulation Auditory-gustatory stimulation Stimuli Light touch Deep pressure Cold washcloth Warm washcloth Familiar pictures (scrap-/yearbook/photos) Unfamiliar pictures (magazine / television) Pleasant odor (cologne / lemon juice) Unpleasant odor (vinegar/rubbing alcohol) Positive taste (soda/ apple juice) Negative taste (lemon juice)

10 Intervention Implementers 7 young adults (M age 22.3), 4 females & 3 males They were classmates & friends. None had any training in speech-language pathology. They had a high school education & were employed. They received verbal & written instructions regarding: Arranging equipment and positioning themselves 5 modality pairs & their presentation Delivery of each stimulus set Observing and coding elicited responses.

11 Intervention Procedures Each session was videotaped and conducted in the subject s room. The stimulation regime was provided daily, 7 days per week across 4 consecutive weeks (28 sessions). Each implementer delivered a session per week (4 sessions per implementer). Behaviors resulting from the delivered stimulus were coded for 4 possible vocal and/ or 6 motor responses. Duration of each session was approximately 30 minutes.

12 Results: Assessment Performance RLA GCS WNSSP Pre Post No significant difference was found between pre- and postintervention for the 3 protocols (t -1.00; df 2; p.42). GCS and RLA scores remained unchanged. WNSSP score showed improvement by 3 points. This protocol was more sensitive in detecting changes.

13 Results: Observed Responses Motor responses occurred in the following order: Labial movements (M = 13.68) Limb movements (M = 11.75) Increased facial tension (M = 8.50) Head turn/roll (M = 7.29) Trunk movement (M = 1.32) Eye opening (M =.14) Vocal responses increased by 4 th week, and showed a hierarchy: Deep breaths/sighs (M = 4.57) Grunts/moans (M =.93) Words or phrases never occurred.

14 Results: Vocal vs. Motor Responses Vocal Motor Week 1 Week 4 All 28 sessions Motor responses (M =42.86; SD=11.42) occurred more often than vocal responses (M =5.54; SD=4.87). This difference was statistically significant (t=19.04, df27, p=.00). Both types of responses increased from first to final (4 th ) week.

15 Results: Sensory Modalities Overall high and significant correlation was found between auditory-thermal and auditory-gustatory stimulations (RHO =.79; p.05). Analysis of each stimulus type identified 20 (44%) moderate, yet statistically significant, correlations. The majority of these correlations were for the following stimuli: Thermal (cold, warm) Tactile (light touch, deep pressure) Olfactory (pleasant, unpleasant odor)

16 Results: Stimuli Effect Gustatory Thermal Tactile Olfactory Visual Gustatory: positive taste was more effective. Thermal: cold sensation was more effective. Tactile: deep pressure was more effective. Olfactory: unpleasant odor was more effective. Visual: familiar picture was more effective.

17 Results: Implementers Seventeen (89%) significant correlations were found between implementers in their scoring of observed responses (RHO >.71, p.05). Five of the implementers maintained strong agreement in their coding of observed responses.

18 Conclusions Individuals with chronic and severe TBI can benefit from select forms of multimodal stimulation. Stimulation via primitive sensory modalities (regulating homeostasis and survival) was the most effective because these modalities may be relatively preserved in severe TBI; these sensory signals bypass the thalamus to directly activate the hippocampus and limbic system. Responses are facilitated by select types of stimuli that tend to be relatively intense or potent, and rouse an emotion.

19 Conclusions (contd) Motor responses are readily elicited to delivered stimulation. Familiar, yet diverse, individuals can be effectively trained to deliver multimodal stimulation. Their involvement may facilitate cognitive rehabilitation in severe TBI and be cost effective as well. Rigidity in the stimulation delivery protocol may have a potential drawback by not accommodating for implementers interaction styles. Single ½ hour sessions each day may be insufficient to effect significant improvement across four-week intervention.

20 References 1. Freeman, W. (1998). The neurobiology of multimodal sensory integration. Integrative Physiological and Behavioral Science, 33, Ito, M. (1998). Consciousness from the viewpoint of the structural-functional relationships of the brain. International Journal of Psychology, 33, Adolphs, R., Tranel, D., & Buchanan, T. (2005). Amydala damage impairs emotional memory for gist but not details of complex stimuli. Nature Neuroscience, 8, Papps, B., Calder, A., Young, A., & O Carroll, R. (2003). Dissociation of affective modulation of recollective and perceptual experience following amygdala damage. Journal of Neurology Neurosurgery and Psychiatry, 74, Lippert-Gruner, M., Wedekind, C., & Klug, N. (2003). Outcome of prolonged coma following severe traumatic brain injury. Brain Injury, 17, Lippert-Gruner, M., & Terhaag, D. (2000). Multimodal early onset stimulation (MEOS) in rehabilitation after brain injury. Brain Injury, 14, Lombardi, F., Taricco, M., De Tanti, A., Telaro, E., & Liberati, A. (2002). Sensory stimulation of brain-injured individuals in coma or vegetative state: Results of a Cochrane systematic review. Clinical Rehabilitation, 16, Doman, G., Wilkinson, R., Dimancescu, M., & Pelligra, R. (1993). The effect of intense multisensory stimulation on coma arousal and recovery. Neuropsychological Rehabilitation, 3, Mitchell, S., Bradley, V., Welch, J., & Britton, P. (1990). Coma arousal procedure: A therapeutic intervention in the treatment of head injury. Brain Injury, 4, Oh, H. & Seo, W. (2003). Sensory stimulation programme to improve recovery in comatose patients. Journal of Clinical Nursing, 12, Wilson, S., Powell, G., Elliot, K., & Thwaites, H. (1991). Sensory stimulation in prolonged coma: Four single case studies. Brain Injury, 5, Teasdale, G., & Jennett, B. (1974). Assessment of coma and impaired consciousness: A practical scale. Lancet, 2, Hagen, C. (1982). Language-cognitive disorganization following closed head injury: A conceptualization. In L.E. Trexler (Ed.), Cognitive rehabilitation: Conceptualization and intervention (pp ). New York: Plenum. 14. Hagen, C. (2000). Rancho Los Amigos Levels of Congitive Functioning-Revised. Presentation at TBI Rehabilitation in a Managed Care Environment: An Interdisciplinary Approach to Rehabilitation. Continuing Education Programs of America, San Antonio, TX. 15. Ansell, B., Keenan, J., & de la Rocha, O. (1989). Western neuro sensory stimulation profile. Tustin, CA: Western Neuro Care Center, Inc.

Effects of Two Sensory Stimulation Models on Recovery in Adults with Severe Traumatic Brain Injury

Effects of Two Sensory Stimulation Models on Recovery in Adults with Severe Traumatic Brain Injury International Journal of Medical Research & Health Sciences Available online at www.ijmrhs.com ISSN No: 2319-5886 International Journal of Medical Research & Health Sciences, 2017, 6(8): 69-74 I J M R