Promoting adaptive behavior in persons with acquired brain injury, extensive motor and communication disabilities, and consciousness disorders

Emergence from Disorders of Consciousness: Optimizing Self-Agency Through Communication

Language and communication deficits are intrinsic to disorders of consciousness. This article will provide an overview of language and communication deficits that can significantly confound the accuracy of diagnostic assessment in these patients. Authors will also discuss interventions to promote early communication using assistive technology and augmentative communication rehabilitation strategies. Finally, this article will discuss the importance of family education as well as ethical considerations connected to the recovery of communication and adaptive strategies to support patient autonomy and enhance self-agency.

Clinical application of recommendations for neurobehavioral assessment in disorders of consciousness: an interdisciplinary approach

Accurate diagnosis, prognosis, and subsequent rehabilitation care planning for persons with Disorders of Consciousness (DoC) has historically posed a challenge for neurological care professionals. Evidence suggests rates of misdiagnosis may be as high as 40% when informal beside evaluations are used to determine level of consciousness. The presence of myriad medical, neurological, functional (motor, sensory, cognitive) and environmental confounds germane to these conditions complicates behavioral assessment. Achieving diagnostic certainty is elusive but critical to inform care planning, clinical decision making, and prognostication. Standardized neurobehavioral rating scales has been shown to improve accuracy in distinguishing between coma, unresponsive wakefulness syndrome/vegetative state and minimally consciousness state as compared to informal assessment methods. Thus, these scales are currently recommended for use as the informal "gold standard" for diagnostic assessment in DoC. The following paper will present an evidence-based approach to neurobehavioral assessment for use in clinical practice. Strategies for optimizing assessment and aiding in identification and management of confounds that can limit diagnostic accuracy will be provided. Finally, clinical application of an interdisciplinary approach to identifying and managing confounds will be discussed and how assessment results can be used to identify trends in performance and guide prognostic counseling with families.

Behavioral intervention approaches for people with disorders of consciousness: a scoping review

PURPOSE

This review was intended to provide an overall picture of work conducted during the last decade to assess the impact of behavioral intervention strategies on people with disorders of consciousness (i.e., comatose state, vegetative state/unresponsive wakefulness, or minimally conscious state). The intervention strategies considered were those not based on music or including music as a component of the intervention package.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist, a scoping review was carried out to identify and provide a synthesis of eligible studies published in English during the 2010-2021 period. Three databases (i.e., PubMed, PsycINFO, and Web of Science) were employed for the literature search.

RESULTS

Forty studies met the inclusion criteria. Those studies were grouped into three categories based on whether they assessed the effects of: (i) verbal stories/messages, (ii) multiple stimulation, and (iii) response-contingent stimulation. Then, a narrative synthesis of the studies of each of the three categories was provided to specify the types of patients involved, the intervention and assessment conditions implemented, and the outcome attained.

CONCLUSIONS

The evidence reported in most of the studies might be considered encouraging and convincing. Even so, it might be very difficult to view the evidence of the various studies cumulatively and make general/conclusive statements due to a number of differences in the intervention conditions applied.Implications for rehabilitationAn informative picture of the studies using behavioral interventions with people with disorders of consciousness is essential to any professional working in the area.Such picture can be highly useful in providing a view of the intervention strategies used for those people, of the variations existing within and across strategies, and of the evidence available.An analysis of the strategies, their implementation and their effects may provide new insights for improving those strategies and eventually increasing their impact.The individuals charged with the implementation process (e.g., family members or nurses) may have a relevant influence on the overall impact of the strategy.

Music Stimulation for People with Disorders of Consciousness: A Scoping Review

Music stimulation is considered to be a valuable form of intervention for people with severe brain injuries and prolonged disorders of consciousness (i.e., unresponsive wakefulness/vegetative state or minimally conscious state). This review was intended to provide an overall picture of work conducted during the last decade to assess the impact of music on behavioral and non-behavioral responses of people with disorders of consciousness. Following the PRISMA-ScR checklist, a scoping review was carried out to identify and provide a synthesis of eligible studies published in English during the 2010–2021 period. Three databases (i.e., PubMed, PsycINFO, and Web of Science) were employed for the literature search. Thirty-four studies met the inclusion criteria. Those studies were grouped into three categories based on whether they assessed the effects of: (i) recorded music, (ii) interactive music, or (iii) response-contingent music. A narrative synthesis of the studies of each of the three categories was eventually provided. While the studies of all three categories reported fairly positive/encouraging results, several methodological questions make it difficult to draw conclusions about those results and their implications for intervention programs in daily contexts.

Assistive technology to help persons in a minimally conscious state develop responding and stimulation control: Performance assessment and social rating

BACKGROUND

Post-coma persons in a minimally conscious state (MCS) and with extensive motor impairment and lack of speech tend to be passive and isolated.

OBJECTIVE

This study aimed to (a) further assess a technology-aided approach for fostering MCS participants' responding and stimulation control and (b) carry out a social validation check about the approach.

METHODS

Eight MCS participants were exposed to the aforementioned approach according to an ABAB design. The technology included optic, pressure or touch microswitches to monitor eyelid, hand or finger responses and a computer system that allowed those responses to produce brief periods of positive stimulation during the B (intervention) phases of the study. Eighty-four university psychology students and 42 care and health professionals were involved in the social validation check.

RESULTS

The MCS participants showed clear increases in their response frequencies, thus producing increases in their levels of environmental stimulation input, during the B phases of the study. The students and care and health professionals involved in the social validation check rated the technology-aided approach more positively than a control condition in which stimulation was automatically presented to the participants.

CONCLUSIONS

A technology-aided approach to foster responding and stimulation control in MCS persons may be effective and socially desirable.

EXTENDING THE ASSESSMENT OF TECHNOLOGY-AIDED PROGRAMS TO SUPPORT LEISURE AND COMMUNICATION IN PEOPLE WITH ACQUIRED BRAIN INJURY AND EXTENSIVE MULTIPLE DISABILITIES

Intervention programs for people with acquired brain injury and extensive motor and communication impairment need to be diversified according to their characteristics and environment. These two studies assessed two technology-aided programs for supporting leisure (i.e., access to songs and videos) and communication (i.e., expressing needs and feelings and making requests) in six of those people. The three people participating in Study 1 did not possess speech but were able to understand spoken and written sentences. Their program presented leisure and communication options through written phrases appearing on the computer screen. The three people participating in Study 2 did not possess any speech and were unable to understand spoken or written language. Their program presented leisure and communication options through pictorial images. All participants relied on a simple microswitch response to enter the options and activate songs, videos, and communication messages. The data showed that the participants of both studies learned to use the program available to them and to engage in leisure and communication independently. The importance of using programs adapted to the participants and their environment was discussed.

Supporting self-managed leisure engagement and communication in post-coma persons with multiple disabilities

Post-coma persons affected by extensive motor impairment and lack of speech, with or without disorders of consciousness, need special support to manage leisure engagement and communication. These two studies extended research efforts aimed at assessing basic technology-aided programs to provide such support. Specifically, Study I assessed a program for promoting independent stimulation choice in four post-coma persons who combined motor and speech disabilities with disorders of consciousness (i.e., were rated between the minimally conscious state and the emergence from such state). Study II assessed a program for promoting independent television operation and basic communication in three post-coma participants who, contrary to those involved in Study I, did not have disorders of consciousness (i.e., had emerged from a minimally conscious state). The results of the studies were largely positive with substantial levels of independent stimulation choice and access for the participants of Study I and independent television operation and communication for the participants of Study II. The results were analyzed in relation to previous data in the area and in terms of their implications for daily contexts dealing with these persons.

Technology-aided programs for post-coma patients emerged from or in a minimally conscious state

Post-coma persons in a minimally conscious state (MCS) or emerged/emerging from such state (E-MCS), who are affected by extensive motor impairment and lack of speech, may develop an active role and interact with their environment with the help of technology-aided intervention programs. Although a number of studies have been conducted in this area during the last few years, new evidence about the efficacy of those programs is warranted. These three studies were an effort in that direction. Study I assessed a technology-aided program to enable six MCS participants to access preferred environmental stimulation independently. Studies II and III assessed technology-aided programs to enable six E-MCS participants to make choices. In Study II, three of those participants were led to choose among leisure and social stimuli, and caregiver interventions automatically presented to them. In Study III, the remaining three participants were led to choose (a) among general stimulus/intervention options (e.g., songs, video-recordings of family members, and caregiver interventions); and then (b) among variants of those options. The results of all three studies were largely positive with substantial increases of independent stimulation access for the participants of Study I and independent choice behavior for the participants of Studies II and III. The results were analyzed in relation to previous data and in terms of their implications for daily contexts working with MCS and E-MCS persons affected by multiple disabilities.

Microswitch-aided programs with contingent stimulation versus general stimulation programs for post-coma persons with multiple disabilities

OBJECTIVE

Assessing the impact of microswitch-aided programs with contingent stimulation on response engagement (Study I) and post-session alertness (Study II) of post-coma participants with multiple disabilities.

METHOD

Study I included three participants whose scores on the Coma Recovery Scale-Revised (CRS-R) were 11 or 13. Study II included three participants whose CRS-R scores were 19, 13, and 14. In both studies, the participants received sessions with contingent stimulation (i.e., sessions in which activation of a microswitch with an eyelid or hand response produced 15 s of preferred stimulation) and sessions with general, non-contingent stimulation (i.e., stimulation lasted throughout the sessions).

RESULTS

Study I showed an increase in response engagement/frequencies only during the contingent stimulation sessions. Study II showed that the participants' level of vigilance after those sessions was higher than after non-contingent stimulation sessions.

CONCLUSION

Microswitch-aided programs with contingent stimulation would be more beneficial than programs with general/non-contingent stimulation.

Technology-based intervention programs to promote stimulation control and communication in post-coma persons with different levels of disability

Post-coma persons in a minimally conscious state and with extensive motor impairment or emerging/emerged from such a state, but affected by lack of speech and motor impairment, tend to be passive and isolated. A way to help them develop functional responding to control environmental events and communication involves the use of intervention programs relying on assistive technology. This paper provides an overview of technology-based intervention programs for enabling the participants to (a) access brief periods of stimulation through one or two microswitches, (b) pursue stimulation and social contact through the combination of a microswitch and a sensor connected to a speech generating device (SGD) or through two SGD-related sensors, (c) control stimulation options through computer or radio systems and a microswitch, (d) communicate through modified messaging or telephone systems operated via microswitch, and (e) control combinations of leisure and communication options through computer systems operated via microswitch. Twenty-six studies, involving a total of 52 participants, were included in this paper. The intervention programs were carried out using single-subject methodology, and their outcomes were generally considered positive from the standpoint of the participants and their context. Practical implications of the programs are discussed.

Further evaluation of a telephone technology for enabling persons with multiple disabilities and lack of speech to make phone contacts with socially relevant partners

This study assessed whether a girl and a woman with multiple disabilities could (a) make phone contacts with relevant partners through a special telephone technology, and (b) enjoy their telephone-mediated communication with them. The technology involved a net-book computer, a global system for mobile communication modem (GSM), an optic microswitch, and specific software. The technology was programmed to present the names of the partners available for contact, and the participants could choose at each presentation sequence the one they wanted to contact with a simple microswitch response. Such response triggered the computer to place a phone call to that partner. Both participants (a) learned to use the technology quite rapidly to contact relevant partners and maintained the successful use of it over the intervention and post-intervention sessions, (b) showed high levels of indices of happiness during the phone calls as opposed to pre-baseline control sessions, and (c) showed preferences among the partners. Implications of the findings are discussed.

Post-coma persons emerging from a minimally conscious state with multiple disabilities make technology-aided phone contacts with relevant partners

Post-coma individuals emerging from a minimally conscious state with multiple disabilities may enjoy contact with relevant partners (e.g., family members and friends), but may not have easy access to them. These two single-case studies assessed whether those individuals could make contact with partners through computer-aided telephone technology and enjoy such contact. The technology involved a computer system with special software, a global system for mobile communication modem (GSM), and microswitch devices. In Study I, the computer system presented a 23-year-old man the names of the partners that he could contact, one at a time, automatically. Together with each partner's name, the system also presented the voice of the partner asking the man whether he wanted to call him or her. The man could (a) place a call to that partner by activating a camera-based microswitch through mouth movements or (b) bypass that partner and wait for the next one to be presented. In Study II, the system presented a 36-year-old man the partners' names only after he had activated his wobble microswitch with a hand movement. The man could place a call or bypass a partner as in Study I. The results showed that both men (a) were able to contact relevant partners through the technology, (b) seemed to enjoy their telephone-mediated communication contacts with the partners, and (c) showed preferences among the partners. Implications of the findings are discussed.

Technology-aided recreation and communication opportunities for post-coma persons affected by lack of speech and extensive motor impairment

This study assessed technology-aided intervention programs for two post-coma men who had re-acquired consciousness, but were unable to engage in personally or socially relevant occupations, given their lack of functional speech and their extensive motor disabilities. The microswitches used for accessing the program contents consisted of (a) a pressure sensor fixed in the palm of the first man's hand that could be activated with a small hand closure movement, and (b) an optic sensor fixed under the chin of the second man that could be activated by mouth opening movements. The programs' content consisted of recreation and communication options, which involved activating music, videos, and basic requests, sending and receiving (listening to) text messages, and placing phone calls. The results showed that the men (a) used the technology-aided programs successfully to manage the recreation and communication options available and (b) showed consistent preference for the sessions with the technology-aided program over other daily events. Family and staff members interviewed about the participants' programs (seven members for each participant) thought that the participants enjoyed the intervention sessions with the programs and that the programs had beneficial effects for them. Implications of the findings are discussed.

Technology-aided leisure and communication opportunities for two post-coma persons emerged from a minimally conscious state and affected by multiple disabilities

This study assessed technology-aided programs for helping two post-coma persons, who had emerged from a minimally conscious state and were affected by multiple disabilities, to (a) engage with leisure stimuli and request caregiver's procedures, (b) send out and listen to text messages for communication with distant partners, and (c) combine leisure engagement and procedure requests with text messaging within the same sessions. The program for leisure engagement and procedure requests relied on the use of a portable computer with commercial software, and a microswitch for the participants' response. The program for text messaging communication involved the use of a portable computer, a GSM modem, a microswitch for the participants' response, and specifically developed software. Results indicated that the participants were successful at each of the three stages of the study, thus providing relevant evidence concerning performance achievements only minimally documented. The implications of the findings in terms of technology and practical opportunities for post-coma persons with multiple disabilities are discussed.