Effectiveness of Sensory Stimulation to Improve Arousal and Alertness of People in a Coma or Persistent Vegetative State After Traumatic Brain Injury: A Systematic Review

A National Survey on Coma Epidemiology, Evaluation, and Therapy in India: Revisiting the Curing Coma Campaign Come Together Survey

BACKGROUND

The limited representation from developing countries in the original COME TOGETHER survey gave us an impetus to conduct this survey in the Indian subcontinent.

METHODS

This cross-sectional online survey was conducted from August through September 2022. Participants were health care physicians caring for patients with coma and disorders of consciousness. Fischer's exact test or the Mann-Whitney U-test was used to compare respondents who agreed or disagreed with the preestablished coma definition. Fleiss κ values were calculated to assess agreement among respondents. A p value less than 0.05 was considered statistically significant.

RESULTS

The survey was completed by 130 physicians. We found substantial interrater agreement on absence of wakefulness (71.54%; κ = 0.71), Glasgow Coma Score ≤ 8 (78.46%; κ = 0.78), and failure to respond purposefully to visual, verbal, or tactile stimuli (66.15%; κ = 0.66). Reported common etiologies of coma included traumatic brain injury (50.76%), ischemic stroke (30%), and intracerebral hemorrhage (29.23%). The most common clinical assessment tools used for coma included the Glasgow Coma Score (92.3%) and neurological examination (60.8%). Neurological examination was the most common diagnostic tool used (100%), followed by magnetic resonance imaging (89.2%), basic laboratory studies (88.5%), and head computed tomography/angiography (86.9%). Pharmacological interventions used to stimulate arousal in patients with coma were sedation vacation (91.5%), electrolyte/endocrine correction (65.4%), osmotic therapy with mannitol (60%), hypertonic saline (54.6%), modafinil (46.9%), and antidote for drugs (45.4%). Among the nonpharmacological interventions, sensory stimulation (57.7%) was the most commonly used modality. The most common discharge disposition for comatose patients who survived hospitalization were home with or without services (70.0%).

CONCLUSIONS

Differences from the global survey were noted regarding the following: traumatic brain injury being the most common etiology of coma in India, more frequent practice of sedation interruption, less frequent use of electroencephalography in India, rare use of pharmacological neurostimulants, and home being the most common discharge disposition in India.

Sensory approaches for adults with severe or profound and multiple learning disabilities: A systematic literature review

Introduction

Sensory approaches are often used by Occupational Therapists working with clients with a severe or profound and multiple learning disabilities (SLD/PMLD). The aims of this review were to synthesise the outcomes of sensory approaches for adults with an SLD/PMLD and describe the key intervention components.

Method

A mixed methods literature review of three databases was completed to identify studies where sensory approaches were used for clients with an SLD/PMLD. Peer-reviewed research articles published between January 1990 and April 2021 were included. Data quality was assessed using the Mixed Methods Appraisal Tool. A convergent-segregated approach to synthesis was taken, including thematic analysis of qualitative data and a narrative review of quantitative data.

Results

Eighteen studies were included. Positive outcomes were reductions in challenging behaviour, stress and improved engagement, attention and communication. Three themes emerged, suggesting important components of sensory approaches for clients with an SLD/PMLD: matching sensory stimuli to the needs of the individual, sensory integration therapists and caregivers as facilitators and increased intervention duration and frequency.

Conclusion

Evidence suggests that sensory approaches support positive social, emotional and cognitive outcomes for individuals with an SLD/PMLD. Essential features of sensory approaches for this client group are sensitive use of sensory stimuli, skilled facilitators and more intensive intervention protocols.

Music, occupational, physical, and speech therapy interventions for patients in disorders of consciousness: An umbrella review

BACKGROUND

Current clinical guidelines recommend that a multidisciplinary team inclusive of allied healthcare practitioners deliver assessment and intervention for disorders of consciousness. Allied health professionals include music, occupational, physical, and speech therapists. These allied health clinicians are challenged to select interventions due to a lack of evidence-based recommendations regarding rehabilitation interventions that support recovery of consciousness. This umbrella review synthesizes available systematic reviews (SRs) that describe occupational, speech and language, physical and/or musical therapeutic interventions for people with disorders of consciousness.

OBJECTIVES

Identify and summarize evidence from systematic reviews (SRs) that examine allied healthcare interventions for patients with disorders of consciousness. Additionally, this umbrella review aims to evaluate the impact of allied health interventions on recovery of consciousness, methodological quality and risk of bias for the included systematic reviews.

METHODS

An umbrella review was completed. The review was reported according to the Preferred Reporting Items for Overview of Reviews (PRIOR) guidance. Five academic databases (PubMed, CINAHL, PsycInfo, Web of Science, and the Cochrane Library) were searched for SRs and/or meta-analyses of allied health (i.e., music, occupational, physical, and speech therapy) interventions for disorders of consciousness. For included studies, data were extracted and quality of the SRs appraised using the A Measurement Tool to Assess Systematic Reviews (AMSTAR) 2 checklist. Data extracted from each SR identified the authors and years of primary studies, interventions, comparators, and outcomes related to recovery of consciousness (i.e., neurobehavioral/cognitive), functional status, physiological response pain, and adverse events. Rehabilitation interventions were categorized and described.

RESULTS

Fifteen SRs were included and three of these reviews conducted meta-analyses. Identified rehabilitation interventions included: 1) sensory stimulation, 2) median nerve stimulation, 3) communication/environmental control through assistive technology, 4) mobilization, and 5) music-based therapy. SRs were published between 2002 and 2022 and included 2286 participants. Using the AMSTAR 2, the quality of reviews was critically low (k = 6), low (k = 3), moderate (k = 4), and high (k = 2). SRs within this umbrella review demonstrated significant heterogeneity in research methods and use of outcome measures to evaluate the recovery of consciousness within the primary studies. These factors influenced the ability to conduct meta-analyses.

CONCLUSIONS

Sensory stimulation, median nerve stimulation, music therapy and mobilization are all interventions that demonstrate some level of benefit, but current SRs fail to prove benefit through high-level quality evidence. There is an indisputable need for continued rehabilitation research to expand options for treatment modalities and to ensure that the interventions being applied to DoC rehabilitation are evidence-based to improve consciousness and recovery.

Efficacy of Multimodal Sensory Therapy in Adult Acquired Brain Injury: A Systematic Review

Adults who experience an acquired brain injury often experience disorders of consciousness, physical difficulties, and maladaptive behaviours. Multimodal sensory therapy may benefit brain injured patients, however the extent this therapy can facilitate rehabilitation is not well understood. This systematic review aimed to synthesize multimodal sensory therapy research for adults affected by acquired brain injury. PRISMA guidelines were followed and searches for work published up until July 2021 were undertaken in 5 databases, finding 1054 articles. 43 articles were included in the study. Results describe 29 studies related to coma following an acquired brain injury and 14 to no coma studies (mostly stroke). Multimodal sensory therapy was mostly used as a coma arousal technique following traumatic brain injury, finding positive effects. Multimodal sensory therapy was less applied in stroke, no coma rehabilitation, where most studies found improvement in somatosensory sensation and motor control in an affected limb. In several no coma studies, effects were maintained after several months. The most common senses stimulated in coma studies were audio (N = 30), tactile (N = 28), visual (N = 26), olfactory (N = 22), and gustatory (N = 17), while the most common senses stimulated in stroke, no coma studies were proprioception (N = 7), tactile (N = 8), and stereognosis (N = 4). Multimodal sensory therapy can be beneficial for patients, especially those in a minimally conscious state or attempting physical rehabilitation following stroke. Negative findings are infrequent in the current literature base. Multimodal sensory therapy appears to be a low-risk intervention with positive outcomes.

Interventions Facilitating Recovery of Consciousness Following Traumatic Brain Injury: A Systematic Review

People who experience disorders of consciousness (DoC) following a severe traumatic brain injury (TBI) have complex rehabilitation needs addressed by occupational therapy. To examine the effectiveness of interventions to improve arousal and awareness of people with DoC following a TBI. For this systematic review, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched six databases in collaboration with a research librarian. Twenty-seven studies were included and grouped thematically. Multimodal sensory stimulation, familiar voices telling structured stories, and transcranial direct current stimulation had a moderate level of evidence. Multimodal sensory stimulation had the strongest evidence in support of its use in clinical practice. Occupational therapy practitioners should administer multimodal stimuli frequently as studies reported administering these interventions at least twice daily. Occupational therapy practitioners should incorporate personally relevant, meaningful, salient stimuli into interventions when treating patients with DoC.

A Novel Neurorehabilitation Approach for Neural Plasticity Overstimulation and Reorganization in Patients with Neurological Disorders

Neurological disorders are those that are associated with impairments in the nervous system. These impairments affect the patient’s activities of daily living. Recently, many advanced modalities have been used in the rehabilitation field to treat various neurological impairments. However, many of these modalities are available only in clinics, and some are expensive. Most patients with neurological disorders have difficulty reaching clinics. This review was designed to establish a new neurorehabilitation approach based on the scientific way to improve patients’ functional recovery following neurological disorders in clinics or at home. The human brain is a network, an intricate, integrated system that coordinates operations among billions of units. In fact, grey matter contains most of the neuronal cell bodies. It includes the brain and the spinal cord areas involved in muscle control, sensory perception, memory, emotions, decision-making, and self-control. Consequently, patients’ functional ability results from complex interactions among various brain and spinal cord areas and neuromuscular systems. While white matter fibers connect numerous brain areas, stimulating or improving non-motor symptoms, such as motivation, cognitive, and sensory symptoms besides motor symptoms may enhance functional recovery in patients with neurological disorders. The basic principles of the current treatment approach are established based on brain connectivity. Using motor, sensory, motivation, and cognitive (MSMC) interventions during rehabilitation may promote neural plasticity and maximize functional recovery in patients with neurological disorders. Experimental studies are strongly needed to verify our theories and hypothesis.

Transauricular vagus nerve stimulation for patients with disorders of consciousness: A randomized controlled clinical trial

Introduction

Disorders of consciousness (DoCs) are a frequent complication of brain injury disease, and effective treatments are currently lacking. Transauricular vagus nerve stimulation (tVNS) has been proposed as a promising therapeutic method for neurological disorders such as epilepsy and depression. In our previous study, we demonstrated that vagus nerve stimulation promoted recovery in rats with DoCs caused by traumatic brain injury. However, the clinical effect of vagus nerve stimulation on consciousness disorders is unclear. We aimed to investigate the therapeutic efficacy and safety of tVNS in patients with DoCs.

Methods

We conducted a randomized, double-blinded, sham-controlled trial. Patients (N = 60) with DoCs, including minimally conscious state (MCS) and vegetative state/unresponsive wakefulness syndrome, were enrolled and randomized to groups receiving either active or sham tVNS. A frequency of 20 Hz and pulse wave of 200 us was used in the active-tVNS protocol, which was performed in the auricular branch of the vagus nerve in the left outer ear. The sham-tVNS protocol was the same as the active-tVNS protocol although without current input. Both groups of patients also received conventional treatments. Consciousness was evaluated according to the Coma Recovery Scale-Revised before and after the 4-week intervention. We also recorded the type and number of behavioral responses. Safety was primarily assessed according to the incidence of treatment-emergent adverse events. Each patient's heart rate and blood pressure were monitored during all treatment sessions.

Results

Ultimately, 57 patients completed the study: 28 patients underwent active tVNS and 29 patients underwent sham tVNS. No significant differences were observed in Coma Recovery Scale-Revised scores between the active- and sham-tVNS groups before the tVNS sessions. Compared with patients in the sham-tVNS group (9.28 ± 4.38), patients with DoCs treated with active tVNS showed improved consciousness (10.93 ± 4.99), although not statistically significant. Further analysis revealed obvious differences between patients with MCS receiving active and sham tVNS, but no significant difference in patients with vegetative state/unresponsive wakefulness syndrome in both groups. All side effects were considered common medical conditions with no obvious correlation to tVNS.

Conclusion

These preliminary data provide early evidence that tVNS may be an effective and safe approach for promoting the recovery of consciousness, especially in patients with MCS.

Clinical trial registration

https://www.chictr.org.cn/edit.aspx?pid=175938&htm=4, identifier: ChiCTR2200066629.

Responses to stimuli in the 'snoezelen' room in unresponsive wakefulness or in minimally responsive state

BACKGROUND

Sensory stimulation in Snoezelen room increased responsiveness after brain injury and dementia.

OBJECTIVE

To explore the physiological and clinical effects of Snoezelen stimulation in persons with unresponsive wakefulness syndrome or minimally conscious state (UWS or MCS).

DESIGN

A comparative prospective observational cohort study.

METHODS

Ten patients with UWS and 25 in MCS were exposed to consecutive stimuli involving the 5 senses in a Snoezelen room. Heart rate (HR) and cerebral blood flow velocity (CBFV), and scores of the Loewenstein communication scale (LCS) were obtained before and during or after the stimuli.

RESULTS

The stimuli increased HR values and decreased left hemisphere CBFV values in patients with MCS (p < 0.05). Stimulation increased LCS scores (from 28.48 ± 6.55 to 31.13 ± 7.14; p < 0.001) in patients with MCS, but not in the UWS group. LCS gain correlated with HR and right hemisphere CBFV gains in patients with MCS (r = 0.439 and 0.636 respectively, p < 0.05).

CONCLUSIONS

Snoezelen stimulation induced immediate improvement in communication and physiological changes in patients with MSC, and had a minor physiological effect in patients with UWS. If additional studies support these findings, it will be possible to suggest that Snoezelen stimulation can affect arousal, and possibly improve functioning.

A simple intervention for disorders of consciousness- is there a light at the end of the tunnel?

Sleep is a physiological state necessary for memory processing, learning and brain plasticity. Patients with disorders of consciousness (DOC) show none or minimal sign of awareness of themselves or their environment but appear to have sleep-wake cycles. The aim of our study was to assess baseline circadian rhythms and sleep in patients with DOC; to optimize circadian rhythm using an intervention combining blue light, melatonin and caffeine, and to identify the impact of this intervention on brain function using event related potentials. We evaluated baseline circadian rhythms and sleep in 17 patients with DOC with 24-h polysomnography (PSG) and 4-hourly saliva melatonin measurements for 48 h. Ten of the 17 patients (5 female, age 30-71) were then treated for 5 weeks with melatonin each night and blue light and caffeine treatment in the mornings. Behavioral assessment of arousal and awareness [Coma recovery scale-revised (CRS-R)], 24-h polysomnography and 4-hourly saliva melatonin measurements, oddball mismatch negativity (MMN) and subject's own name (SON) experiments were performed twice at baseline and following intervention. Baseline sleep was abnormal in all patients. Cosinor analysis of saliva melatonin results revealed that averaged baseline % rhythmicity was low (M: 31%, Range: 13-66.4%, SD: 18.4). However, increase in % Melatonin Rhythm following intervention was statistically significant (p = 0.012). 7 patients showed improvement of CRS-R scores with intervention and this was statistically significant (p = 0.034). All the patients who had improvement of clinical scores also had statistically significant improvement of neurophysiological responses on MMN and SON experiments at group level (p = 0.001). Our study shows that sleep and circadian rhythms are severely deranged in DOC but optimization is possible with melatonin, caffeine and blue light treatment. Clinical and physiological parameters improved with this simple and inexpensive intervention. Optimization of sleep and circadian rhythms should be integrated into rehabilitation programs for people with DOC.

Critical review of multisensory integration programs and proposal of a theoretical framework for its combination with neurocognitive training

INTRODUCTION

The main purpose of this manuscript is to critically review the Multisensory Integration (MI) training programs applied to older adults, their characteristics, target sensory systems, efficacy, assessment methods, and results. We also intend to propose an integrated framework to support combined interventions of neurocognitive and sensory training.

AREAS COVERED

A critical review was conducted covering the most relevant literature on the MI training programs applied to older adults. Two MI training programs applied to cognitively healthy older adults were found: (a) audio-visual temporal discrimination training and (b) simultaneity judgment training. Both led to the improvement of the MI between pre- and post-training. However, only the audio-visual temporal discrimination training led to the generalization of the improvements to another MI task.

EXPERT OPINION

Considering the relationship between sensory and cognitive functioning, this review supports the potential advantages of combining MI with neurocognitive training in the rehabilitation of older adults. We suggested that this can be achieved within the framework of Branched Programmed Neurocognitive Training (BPNT). Criteria for deciding the most suitable multisensory intervention, that is, MI or Multisensory Stimulation, and general guidelines for the development of MI intervention protocols with older adults with or without cognitive impairment are provided.

Comparison of the Effect of Reflexology and Swedish Massage on Restless Legs Syndrome and Sleep Quality in Patients Undergoing Hemodialysis: a Randomized Clinical Trial

BACKGROUND

Patients undergoing hemodialysis experience painful complications such as restless leg syndrome and poor sleep quality, which negatively affect their quality of life.

PURPOSE

This study aimed to compare the effect of reflexology and Swedish massage on restless leg syndrome and sleep quality in patients undergoing hemodialysis.

METHOD

This is a randomized clinical trial conducted on 90 patients undergoing hemodialysis. The two intervention groups received either foot reflexology (n = 30) or Swedish massage (n = 30) for four weeks. In the sham group (n = 30), a simple touch of the knee down was performed with the same conditions as the intervention groups. Each sample completed the International Restless Leg Syndrome and Pittsburgh Sleep Quality Index Questionnaires before, immediately after, and one month after the intervention.

RESULT

The results showed that immediately after the intervention, restless leg syndrome and sleep quality were significantly better in the foot reflexology massage group than the Swedish massage and sham groups (PRLS < 0.001, PPSQI < 0.001); also, changes in restless leg syndrome and sleep quality, respectively, before and one-month follow-up after the intervention were not significant in all three groups (PRLS = 0.47, PPSQI = 0.95), (PRLS = 0.91, PPSQI = 0.87).

CONCLUSION

Reflexology and Swedish massage, as complementary methods, can improve the restless leg syndrome and sleep quality of patients undergoing hemodialysis. However, foot reflexology massage had been more effective.

Effect of Low Frequency Repetitive Transcranial Magnetic Stimulation (rTMS) Combined with Hyperbaric Oxygen (HBO) on Awakening of Coma Patients with Traumatic Brain Injury

Coma caused by craniocerebral injury is a common condition of neurosurgical acute injury. There is no specific method to promote awakening in a clinic. Early comprehensive treatment may be helpful to patients. The common methods are hyperbaric oxygen (HBO) and low-frequency repetitive transcranial magnetic stimulation (rTMS). However, the application effect and mechanism of rTMS combined with HBO on coma patients with traumatic brain injury need to be further studied. The brain stem auditory evoked potential (BAEP) is examined by the Kennedy coma recovery scale (CRS-R), the recovery of brain function and the state of consciousness are evaluated, and the therapeutic effect is evaluated by the Glasgow Coma Scale (GCS). Cerebrospinal fluid NE level, MCA blood flow velocity, and left brainstem and right brainstem auditory evoked potential are used to evaluate brain rehabilitation. RTMS combined with HBO could shorten the wake-up time, improve the wake-up rate, improve the GCS score and CRS-R score, shorten the brain wave latency time of the left and right brainstem, increase the NE level of cerebrospinal fluid, and decrease the blood flow velocity of MCA. RTMS combines with HBO can improve the nerve excitability of brain cells, reduce the disturbance of consciousness, promote the functional recovery of brain injury, and has a certain role in promoting the awakening of patients with traumatic brain injury coma.

Effect of Foot Reflexology on Sexual Function of Patients under Hemodialysis: A Randomized Parallel Controlled Clinical Trial

INTRODUCTION

Hemodialysis patients experience sexual dysfunction due to the nature of their disease and its complications. Dialysis patients have reported sexual dysfunction as one of the most important stressors, which leads to many psychological and physiological problems. Sexual function in hemodialysis patients has been improved with pharmaceutical and nonpharmacological therapies. Foot reflexology is a complementary and alternative treatment that can be used in conjunction with contemporary care. By activating the chemical nerve system, reflexology may balance enzymes and regulate endocrine function.

OBJECTIVES

To determine the effect of foot reflexology on the sexual function of hemodialysis patients.

METHODS

This randomized controlled trial was conducted on 47 patients on chronic hemodialysis referred to Imam Reza Hospital in Sirjan, Iran, who were divided into two groups of reflexology (n = 24; male = 19 and female = 5) and sham (n = 23; male = 18, and female = 5). The intervention group received foot reflexology during dialysis for four weeks, three times a week, 30 minutes each time (15 minutes per foot). The sham group received nonspecific foot massage without applying pressure on standard reflex points with the same condition and duration as the intervention group. The international index of erectile function and female sexual function index was assessed before, immediately, and one month after the intervention.

RESULTS

The results showed that immediately after the intervention, male orgasm function, sexual desire, and intercourse satisfaction in the reflexology group was significantly higher than those of the sham group. There was no significant difference between the two groups regarding erectile function and overall satisfaction. Furthermore, there was no significant difference between the two groups in terms of different aspects of female sexual function.

CONCLUSIONS

Foot reflexology, as an effective intervention treatment, can reduce some aspects of sexual dysfunction of male patients under hemodialysis.

Akinetic mutism reversed by inferior parietal lobule repetitive theta burst stimulation: Can we restore default mode network function for therapeutic benefit?

BACKGROUND

Transcranial magnetic stimulation is a noninvasive treatment used to modulate cortical excitability. Its use over the last two decades has expanded, ranging from psychiatric disorders to traumatic brain injury and poststroke rehabilitation.

OBJECTIVES

We present the case of a 59-year-old male patient who presented in a decreased state of consciousness due to a right frontal glioblastoma, wherein his state was not improved by a successful surgery and could not be explained by any other condition. Due to his poor prognosis, we examine the benefits of receiving transcranial magnetic stimulation treatment to improve his akinetic mutism.

METHODS

We utilized independent component analysis with resting-state functional magnetic resonance imaging (rsfMRI) to better understand his cortical functionality. The imaging suggested absence of the default mode network (DMN). The patient underwent five sessions of navigated intermittent theta burst stimulation to the ipsilesional inferior parietal lobule and inferior frontal gyrus, with the aim of improving his default mode network functionality.

RESULTS

No other treatments resulted in an improvement of this patient's condition; however, 3 weeks following transcranial magnetic stimulation treatment, the patient was more alert and interactive, and his follow-up rsfMRI scan demonstrated a partially intact default mode network.

CONCLUSION

This case raises important questions regarding the clinical utility of transcranial magnetic stimulation to improve the connectivity of important cerebral networks and subsequent related functional recovery.

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.

Wakefulness-Promoting Effects of Lateral Hypothalamic Area-Deep Brain Stimulation in Traumatic Brain Injury-Induced Comatose Rats: Upregulation of α1-Adrenoceptor Subtypes and Downregulation of Gamma-Aminobutyric Acid β Receptor Expression Via the Orexins Pathway

OBJECTIVE

Previous studies have shown that deep brain stimulation (DBS) can improve the level of consciousness of comatose patients with traumatic brain injuries (TBIs). However, the most suitable targets for DBS are unknown, and the mechanisms underlying recovery remain to be determined. The aim of the present study was to assess the effects of lateral hypothalamic area-DBS (LHA-DBS) in comatose rats with TBIs.

METHODS

A total of 55 Sprague-Dawley rats were randomly assigned to 5 groups: the control group, TBI group, stimulated (TBI+LHA-DBS) group, antagonist (TBI+SB334867+LHA-DBS) group, and antagonist control (TBI+saline+LHA-DBS) group. The rats in the control group had undergone a sham operation and anesthesia, without coma induction. Coma was induced using a free-fall drop method. The rats in the stimulated group received bilateral LHA stimulation (frequency, 200 Hz; voltage, 2-4 V; pulse width, 0.1 ms) for 1 hour, with 5-minute intervals between subsequent stimulations, which were applied alternately to the left and right sides of the lateral hypothalamus. The comatose rats in the antagonist group received an intracerebroventricular injection with an orexins receptor type 1 (OX1R) antagonist (SB334867) and then received LHA-DBS. A I-VI consciousness scale and electroencephalography were used to assess the level of consciousness in each group of rats after LHA-DBS. Western blotting and immunofluorescence were used to detect OX1R expression in the LHA and α1-adrenoceptor (α1-AR) subtype and gamma-aminobutyric acid β receptor (GABABR) expression in the prefrontal cortex.

RESULTS

In the TBI, stimulated, antagonist, and antagonist control groups, 5, 10, 6, and 9 rats were awakened. The electroencephalographic readings indicated that the proportion of δ waves was lower in the stimulated group than in the TBI and antagonist groups (P < 0.05). Western blotting and immunofluorescence analysis showed that OX1R expression was greater in the stimulated group than in the TBI group (P < 0.05). The expression of α1-AR was also greater in the stimulated group than in the TBI and antagonist groups (P < 0.05). In contrast, the GABABR levels in the stimulated group were lower than those in the TBI and antagonist groups (P < 0.05). A statistically significant difference was found between the antagonist and antagonist control groups.

CONCLUSIONS

Taken together, these results suggest that LHA-DBS promotes the recovery of consciousness in comatose rats with TBIs. Upregulation of α1-AR expression and downregulation of GABABR expression in the prefrontal cortex via the orexins and OX1R pathways might be involved in the wakefulness-promoting effects of LHA-DBS.

Personalized Clinical Phenotyping through Systems Medicine and Artificial Intelligence

Personalized Medicine (PM) has shifted the traditional top-down approach to medicine based on the identification of single etiological factors to explain diseases, which was not suitable for explaining complex conditions. The concept of PM assumes several interpretations in the literature, with particular regards to Genetic and Genomic Medicine. Despite the fact that some disease-modifying genes affect disease expression and progression, many complex conditions cannot be understood through only this lens, especially when other lifestyle factors can play a crucial role (such as the environment, emotions, nutrition, etc.). Personalizing clinical phenotyping becomes a challenge when different pathophysiological mechanisms underlie the same manifestation. Brain disorders, cardiovascular and gastroenterological diseases can be paradigmatic examples. Experiences on the field of Fondazione Policlinico Gemelli in Rome (a research hospital recognized by the Italian Ministry of Health as national leader in "Personalized Medicine" and "Innovative Biomedical Technologies") could help understanding which techniques and tools are the most performing to develop potential clinical phenotypes personalization. The connection between practical experiences and scientific literature highlights how this potential can be reached towards Systems Medicine using Artificial Intelligence tools.

Rehabilitating the neurological patient in the ICU: what is important?

PURPOSE OF REVIEW

To describe recent literature evaluating the effectiveness of early rehabilitation in neurocritical care patients.

RECENT FINDINGS

There is a drive for early rehabilitation within the ICU; however, there are unique considerations for the neurocritically ill patient that include hemiplegia, cognitive impairments and impaired conscious state that can complicate rehabilitation. Additionally, neurological complications, such as hemorrhage expansion and cerebral edema can lead to the risk of further neurological damage. It is, therefore, important to consider the effect of exercise and position changes on cerebral hemodynamics in patients with impaired cerebral autoregulation. There is a paucity of evidence to provide recommendations on timing of early rehabilitation postneurological insult. There are also mixed findings on the effectiveness of early mobilization with one large, multicenter RCT demonstrating the potential harm of early and intensive mobilization in stroke patients. Conversely, observational trials have found early rehabilitation to be well tolerated and feasible, reduce hospital length of stay and improve functional outcomes in neurological patients admitted to ICU.

SUMMARY

Further research is warranted to determine the benefits and harm of early rehabilitation in neurological patients. As current evidence is limited, and given recent findings in stroke studies, careful consideration should be taken when prescribing exercises in neurocritically ill patients.

The effect of family-centered sensory and affective stimulation on comatose patients with traumatic brain injury: A systematic review and meta-analysis

BACKGROUND

Sensory stimulation has been used in the early rehabilitation of comatose patients with traumatic brain injury, but the effect of sensory stimulation involving family members is unclear.

OBJECTIVES

To evaluate the effects of family-centered sensory and affective stimulation on comatose patients with traumatic brain injury and explore the factors that affect the outcomes.

DESIGN

A systematic review with a meta-analysis.

DATA SOURCES

Electronic databases including PubMed, Web of Science, Google Scholar, Cochrane Library, CINAHL, China National Knowledge Infrastructure, and WanFang were searched from October 2019 to May 2020.

REVIEW METHODS

Two reviewers independently assessed eligibility of potential studies and extracted data. Quality of included studies was assessed according to the evaluation criteria of Cochrane Evaluation Manual 5.1.0. Outcome measures of the meta-analysis were the Glasgow Coma Scale scores, the Western Neuro Sensory Stimulation Profile scores, awakening time, and satisfaction rate. To explore whether there was a difference in the effect between variants of the intervention, variables as subgroups were time to start intervention, type of intervention, duration of each intervention, daily frequency of intervention, days of intervention, and patient's area.

RESULT

Seventeen randomized controlled trials were included in the review and meta-analysis. Most studies were of medium quality. The improvement of the Glasgow Coma Scale score is significantly greater with the intervention implemented within 24 h compared to the intervention implemented 24 h later (mean difference 3.91, 95% confidence interval 3.44-4.38 vs. mean difference 1.90, 95% confidence interval 1.69-2.12, respectively). The results of subgroup analyses show that auditory stimulation combined with tactile stimulation and multi-sensory stimulation are associated with better outcomes than a single use of auditory stimulation. Studies from Asia report more positive outcomes than those from America (mean difference 1.94, 95% confidence interval 1.73-2.16 vs. mean difference 0.44, 95% confidence interval -0.87-1.75). And the improvement of the Glasgow Coma Scale score with the stimulation performed by family members is greater than that with the stimulation implemented by nurses (mean difference 2.17, 95% confidence interval 1.67-2.66). Besides, it is associated with better awakening time, awakening rate, and satisfaction rate compared to routine care.

CONCLUSION

Early family-centered sensory and affective stimulation is more effective than routine care and nurse-implemented sensory stimulation in improving the level of consciousness and cognition of comatose patients with traumatic brain injury, and multi-sensory stimulation is more effective than single stimulation. More studies with larger sample size and high quality in different countries are warranted.

Systematic Review of Sensory Stimulation Programs in the Rehabilitation of Acquired Brain Injury

Abstract. Acquired Brain Injury (ABI) can lead to sensory deficits and compromise functionality. However, most studies have been focused on motor stimulation in stroke and traumatic brain injury (TBI). Sensory stimulation in stroke and mild/moderate TBI has received reduced interest. The main objective of this review is to know the methodological characteristics and effects of sensory programs in ABI. Studies with the purpose of testing the efficacy of those programs were identified through a literature search, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the Cochrane Collaboration Guidelines. Twenty-three studies were included in this review. The results show that in most studies sensory stimulation started within 12 months after injury and there is no consensus regarding frequency, duration and number of sessions, duration of intervention, and instruments used to assess outcomes. Most programs involved unisensory stimulation, and vision was the predominant target. The most used methods were compensation and somatosensory discrimination training. Most studies used a pre- and post-intervention assessment, with few studies comprising follow-up assessment. Regarding the studies revised, the interventions with positive outcomes in ABI are: compensation, cognitive training, vestibular intervention, somatosensory discrimination training, proprioceptive stimulation with muscle vibration, and sustained attention training with olfactory stimulation. Available findings suggest that sensory stimulation has positive results with immediate and long-term improvements in sensory functioning. This review provides useful information to improve rehabilitation and to design future investigation.

The effects of musical stimulation on the level of consciousness among patients with head trauma hospitalized in intensive care units: A randomized control trial

BACKGROUND

Improvement in the level of consciousness (LOC) is considered as an indicator of recovery among patients with head trauma (HT). musical stimulation is a simple noninvasive intervention with potential positive effects on LOC. This study evaluated the effects of musical stimulation on LOC among patients with HT hospitalized in intensive care unit.

METHODS

This clinical trial was conducted in 2018-2019. Fifty-four patients with HT were purposively and consecutively recruited from two trauma intensive care units in Qazvin, Iran, and randomly allocated to a control (n = 27) and an intervention (n = 27) group. Participants in the intervention group received fifteen-minute musical stimulation once daily for seven consecutive days using an MP3 player and a headphone for their counterparts, the headphones were silent for 15 min without receiving any musical stimulation once daily for seven consecutive days. A demographic questionnaire, the Glasgow Coma Scale, and the Richmond Agitation-Sedation Scale were used for data collection. LOC was daily assessed before and after each musical stimulation session. The SPSS program (v. 23.0) was used for data analysis at a significance level of less than 0.05.

FINDINGS

There were significant between-group differences respecting the posttest mean score of LOC in the third, fourth, fifth, sixth, and seventh days of the study intervention (P < 0.05)., the posttest mean score of LOC in the intervention group significantly increased in the intervention group (P < 0.0001), while it did not significantly change in the control group (P > 0.05).

CONCLUSION

musical stimulation is effective in significantly improving LOC among hospitalized patients with HT. Therefore, it can be used as a non-expensive noninvasive intervention to improve treatment outcomes among these patients.

Sensory stimulation to improve arousal in comatose patients after traumatic brain injury: a systematic review of the literature

BACKGROUND

No standard rehabilitative treatment for coma arousal after traumatic brain injury (TBI) exists. Based on our clinical experience, we hypothesized that sensory stimulation (SS) is a promising protocol to improve outcomes in these patients.

METHODS

We performed a literature review on the progress of sensory stimulation to enhance coma arousal after traumatic brain injury. We searched the databases on Medline, Embase, and Cochrane to gain access to relevant publications using the key words "traumatic brain injury," "disorders of consciousness," "sensory stimulation," and "coma scale."

RESULTS

We included all original studies published in English with patients presenting severe disorders of consciousness due to traumatic brain injury who had received SS and whose behavioral/neural responses had been measured. We compared data on ten selected studies and analyzed the SS effects in comatose patient outcomes after TBI. Our review outlines the role of SS in patients with TBI and provides guidance for its implementation in the clinical practice.

CONCLUSIONS

The literature suggests the SS program improves coma arousal after TBI. However, high-quality clinical trials are needed to establish standard SS protocols.

Neurophysiology and Treatment of Disorders of Consciousness Induced by Traumatic Brain Injury: Orexin Signaling as a Potential Therapeutic Target

BACKGROUND

Traumatic brain injury (TBI) can cause disorders of consciousness (DOC) by impairing the neuronal circuits of the ascending reticular activating system (ARAS) structures, including the hypothalamus, which are responsible for the maintenance of the wakefulness and awareness. However, the effectiveness of drugs targeting ARAS activation is still inadequate, and novel therapeutic modalities are urgently needed.

METHODS

The goal of this work is to describe the neural loops of wakefulness, and explain how these elements participate in DOC, with emphasis on the identification of potential new therapeutic options for DOC induced by TBI.

RESULTS

Hypothalamus has been identified as a sleep/wake center, and its anterior and posterior regions have diverse roles in the regulation of the sleep/wake function. In particular, the posterior hypothalamus (PH) possesses several types of neurons, including the orexin neurons in the lateral hypothalamus (LH) with widespread projections to other wakefulness-related regions of the brain. Orexins have been known to affect feeding and appetite, and recently their profound effect on sleep disorders and DOC has been identified. Orexin antagonists are used for the treatment of insomnia, and orexin agonists can be used for narcolepsy. Additionally, several studies demonstrated that the agonists of orexin might be effective in the treatment of DOC, providing novel therapeutic opportunities in this field.

CONCLUSION

The hypothalamic-centered orexin has been adopted as the point of entry into the system of consciousness control, and modulators of orexin signaling opened several therapeutic opportunities for the treatment of DOC.

A group intervention to improve quality of life for people with advanced dementia living in care homes: the Namaste feasibility cluster RCT

BACKGROUND

People with advanced dementia who live and die in nursing homes experience variable quality of life, care and dying. There is a need to identify appropriate, cost-effective interventions that facilitate high-quality end-of-life care provision.

OBJECTIVES

To establish the feasibility and acceptability to staff and family of conducting a cluster randomised controlled trial of the Namaste Care intervention for people with advanced dementia in nursing homes.

DESIGN

The study had three phases: (1) realist review and (2) intervention refinement to inform the design of (3) a feasibility cluster randomised controlled trial with a process evaluation and economic analysis. Clusters (nursing homes) were randomised in a 3 : 1 ratio to intervention or control (usual care). The nature of the intervention meant that blinding was not possible.

SETTING

Nursing homes in England providing care for people with dementia.

PARTICIPANTS

Residents with advanced dementia (assessed as having a Functional Assessment Staging Test score of 6 or 7), their informal carers and nursing home staff.

INTERVENTION

Namaste Care is a complex group intervention that provides structured personalised care in a dedicated space, focusing on enhancements to the physical environment, comfort management and sensory engagement.

MAIN OUTCOME MEASURES

The two contender primary outcome measures were Comfort Assessment in Dying - End of Life Care in Dementia for quality of dying (dementia) and Quality of Life in Late Stage Dementia for quality of life. The secondary outcomes were as follows: person with dementia, sleep/activity (actigraphy), neuropsychiatric symptoms, agitation and pain; informal carers, satisfaction with care at the end of life; staff members, person-centred care assessment, satisfaction with care at the end of life and readiness for change; and other data - health economic outcomes, medication/service use and intervention activity.

RESULTS

Phase 1 (realist review; 86 papers) identified that a key intervention component was the activities enabling the development of moments of connection. In phase 2, refinement of the intervention enabled the production of a user-friendly 16-page A4 booklet. In phase 3, eight nursing homes were recruited. Two homes withdrew before the intervention commenced; four intervention and two control homes completed the study. Residents with advanced dementia (n = 32) were recruited in intervention (n = 18) and control (n = 14) homes. Informal carers (total, n = 12: intervention, n = 5; control, n = 7) and 97 staff from eight sites (intervention, n = 75; control, n = 22) were recruited over a 6-month period. Recruitment is feasible. Completion rates of the primary outcome questionnaires were high at baseline (100%) and at 4 weeks (96.8%). The Quality of Life in Late Stage Dementia was more responsive to change over 24 weeks. Even where economic data were missing, these could be collected in a full trial. The intervention was acceptable; the dose varied depending on the staffing and physical environment of each care home. Staff and informal carers reported changes for the person with dementia in two ways: increased social engagement and greater calm. No adverse events related to the intervention were reported.

CONCLUSIONS

A subsequent definitive trial is feasible if there are amendments to the recruitment process, outcome measure choice and intervention specification.

FUTURE WORK

In a full trial, consideration is needed of the appropriate outcome measure that is sensitive to different participant responses, and of clear implementation principles for this person-centred intervention in a nursing home context.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN14948133.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 6. See the NIHR Journals Library website for further project information.

Comparison of Single and Combined Effects of Nature Sounds and Foot Sole Reflexology Massage on the Level of Consciousness in Traumatic Comatose Patients: A Randomized Controlled Clinical Trial

Consciousness disturbances are the most common posttraumatic complications. The purpose of this study was to compare the single and combined effects of nature sounds and foot sole reflexology massage on level of consciousness in traumatic comatose patients. This randomized controlled clinical trial was conducted in 2 teaching hospitals in an urban area of Iran. Samples were 120 traumatic comatose patients who were randomly assigned into control, nature sounds, foot reflexology massage, and nature sounds plus foot sole reflexology massage groups. Patients in all groups received routine care. Interventions were performed twice a day for 2 weeks, each time for 30 minutes. The patients' level of consciousness was assessed using the Glasgow Coma Scale before, 1 week, and 2 weeks after the intervention. The groups had no significant differences in the mean scores of the consciousness level before, 1 week after, and the last day of the intervention. Also, there was a significant difference in the number of patients who regained full consciousness (P = .001) in the intervention groups compared with the control group. Significant differences in the number of days of consciousness were reported in at least one of the groups compared with other groups (P = .001). This difference was significant in the control group compared with the foot reflexology massage group (P = .032), as well as the nature sounds plus foot sole reflexology massage group (P = .001). Single or combined interventions can increase the level of consciousness in comatose patients and reduce the duration of coma.

Effect of Rehabilitation Treatments on Disability in Persons With Disorders of Consciousness: A Propensity Score Study

OBJECTIVE

To evaluate the effects of rehabilitation (physical and cognitive) treatments on the diagnosis severity and Disability Rating Scale (DRS) scores, adjusted for a number of potential confounders measured at baseline, in a large cohort of patients with disorders of consciousness across time.

DESIGN AND SETTING

An observational, longitudinal (2 evaluations), multicenter project was made in 90 Italian centers.

PARTICIPANTS

Patients (N=364) with a diagnosis of disorders of consciousness.

MAIN OUTCOME MEASURES

Primary outcome was the severity of diagnosis, expressed on an ordinal scale (Other<MCS<VS<death). In the Other group were included patients who emerged from an MCS and recovered consciousness. The secondary outcome was the DRS score (range of 0-30 with 30 being the worst value). The DRS is a tool used to define the level of residual disability, commonly used to classify the level of functional impairment in patients with acquired brain injury. Both outcomes were measured for each wave.

RESULTS

A total of 364 subjects having a complete set of demographic, clinical, and pharmacologic data were included in the propensity score (PS) analysis. Results showed that the rehabilitation treatments (physical and cognitive) reduced the clinical worsening over time in both severity diagnosis and DRS (around 6.5 points) in patients with disorders of consciousness across different propensity score strategies (ie, PS matching, PS adjustment, and PS-weighted procedures). In addition, cognitive protocols seem to be limited to patients with a median value of DRS=23.

CONCLUSIONS

Our propensity score analysis suggests that rehabilitation treatment protocols seem effective and should be applied to a broader spectrum of patients with disorders of consciousness.

Improving living and dying for people with advanced dementia living in care homes: a realist review of Namaste Care and other multisensory interventions

BACKGROUND

Seventy percent of people with advanced dementia live and die in care homes. Multisensory approaches, such as Namaste Care, have been developed to improve the quality of life and dying for people with advanced dementia but little is known about effectiveness or optimum delivery. The aim of this review was to develop an explanatory account of how the Namaste Care intervention might work, on what outcomes, and in what circumstances.

METHODS

This is a realist review involving scoping of the literature and stakeholder interviews to develop theoretical explanations of how interventions might work, systematic searches of the evidence to test and develop the theories, and their validation with a purposive sample of stakeholders. Twenty stakeholders - user/patient representatives, dementia care providers, care home staff, researchers -took part in interviews and/or workshops.

RESULTS

We included 85 papers. Eight focused on Namaste Care and the remainder on other types of sensory interventions such as music therapy or massage. We identified three context-mechanism-outcome configurations which together provide an explanatory account of what needs to be in place for Namaste Care to work for people living with advanced dementia. This includes: providing structured access to social and physical stimulation, equipping care home staff to cope effectively with complex behaviours and variable responses, and providing a framework for person-centred care. A key overarching theme concerned the importance of activities that enabled the development of moments of connection for people with advanced dementia.

CONCLUSIONS

This realist review provides a coherent account of how Namaste Care, and other multisensory interventions might work. It provides practitioners and researchers with a framework to judge the feasibility and likely success of Namaste Care in long term settings. Key for staff and residents is that the intervention triggers feelings of familiarity, reassurance, engagement and connection.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016047512.

Do Sensory Stimulation Programs Have an Impact on Consciousness Recovery?

Objectives: Considering sensory stimulation programs (SSP) as a treatment for disorders of consciousness is still debated today. Previous studies investigating its efficacy were affected by various biases among which small sample size and spontaneous recovery. In this study, treatment-related changes were assessed using time-series design in patients with disorders of consciousness (i.e., vegetative state-VS and minimally conscious state-MCS). Methods: A withdrawal design (ABAB) was used. During B phases, patients underwent a SSP (3 days a week, including auditory, visual, tactile, olfactory, and gustatory stimulation). The program was not applied during A phases. To assess behavioral changes, the Coma Recovery Scale-Revised (CRS-R) was administered by an independent rater on a weekly basis, across all phases. Each phase lasted 4 weeks. In a subset of patients, resting state functional magnetic resonance imaging (fMRI) data were collected at the end of each phase. Results: Twenty nine patients (48 ± 19 years old; 15 traumatic; 21 > a year post-injury; 11 VS and 18 MCS) were included in our study. Higher CRS-R total scores (medium effect size) as well as higher arousal and oromotor subscores were observed in the B phases (treatment) as compared to A phases (no treatment), in the MCS group but not in the VS group. In the three patients who underwent fMRI analyses, a modulation of metabolic activity related to treatment was observed in middle frontal gyrus, superior temporal gyrus as well as ventro-anterior thalamic nucleus. Conclusion: Our results suggest that SSP may not be sufficient to restore consciousness. SSP might nevertheless lead to improved behavioral responsiveness in MCS patients. Our results show higher CRS-R total scores when treatment is applied, and more exactly, increased arousal and oromotor functions.

The effectiveness of non-invasive brain stimulation on arousal and alertness in patients in coma or persistent vegetative state after traumatic brain injury: Protocol of systematic review and network meta-analysis

BACKGROUND

Traumatic brain injury is a leading cause of death and disability worldwide. The survivors usually suffer from disorders of consciousness, especially coma state and persistent vegetative state. For these patients, there is no standard treatment for them, but non-invasive brain stimulations are considered as relatively more acceptable treatments. However, the knowledge regarding the relative effectiveness and the rank of the effectiveness of the non-invasive brain stimulations is limited. Thus, in this study, we aim to conduct a systematic review and network meta-analysis to evaluate the effect of non-invasive train stimulations on arousal and alertness in patients in a coma or persistent vegetative state after traumatic brain injury.

METHODS AND ANALYSIS

A comprehensive search strategy will be performed in the relevant databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), Chinese Biomedical Literature Database, China National Knowledge Infrastructure, Wan Fang Data). The random or quasi-random controlled trails focusing on the effectiveness of the non-invasive brain stimulations will be included. The risk of bias for the included studies will be appraised using the Cochrane collaboration tool for assessing risk of bias. The standard pairwise meta-analysis and a Bayesian network meta-analysis will be conducted.

ETHICS AND DISSEMINATION

This research is a systematic review and network meta-analysis. Thus, there is no requirement of ethical approval and patient informed consent.

PROSPERO REGISTRATION NUMBER

CRD42018104945.

Disorders of consciousness after severe brain injury: therapeutic options

PURPOSE OF REVIEW

Very few options exist for patients who survive severe traumatic brain injury but fail to fully recover and develop a disorder of consciousness (e.g. vegetative state, minimally conscious state).

RECENT FINDINGS

Among pharmacological approaches, Amantadine has shown the ability to accelerate functional recovery. Although with very low frequency, Zolpidem has shown the ability to improve the level of consciousness transiently and, possibly, also in a sustained fashion. Among neuromodulatory approaches, transcranial direct current stimulation has been shown to transiently improve behavioral responsiveness, but mostly in minimally conscious patients. New evidence for thalamic deep brain stimulation calls into question its cost/benefit trade-off.

SUMMARY

The growing understanding of the biology of disorders of consciousness has led to a renaissance in the development of therapeutic interventions for patients with disorders of consciousness. High-quality evidence is emerging for pharmacological (i.e. Amantadine) and neurostimulatory (i.e. transcranial direct current stimulation) interventions, although further studies are needed to delineate preconditions, optimal dosages, and timing of administration. Other exciting new approaches (e.g. low intensity focused ultrasound) still await systematic assessment. A crucial future direction should be the use of neuroimaging measures of functional and structural impairment as a means of tailoring patient-specific interventions.

Effects on the diagnosis change and on the disability level for individuals with disorder of consciousness: which predictors?

Prediction of the functional recovery in patients with disorders of consciousness (DOC) is still complex because of the different numbers of variables that influence the possibility of observing changes in clinical outcome. The aim of the present study is to identify the best set of predictors of the change in DOC diagnosis among different pharmacotherapy and nonpharmacotherapy indicators. This study analyzed data collected in a longitudinal, two-evaluation, multicenter project conducted in 90 centers. We analyzed the predictor effects of physical and cognitive treatments, duration of disease, etiology, age, and sex (nonpharmacological treatments) as well as the use of antiparkinson, psycholeptic, psychoanaleptic, and muscle-relaxant drugs (pharmacological variables). Ordered logistic models, linear regression models with bootstrap estimation, and model averaging procedures were used. The results showed that physical and cognitive treatments [best predictor: odds ratio (OR)=413.3, P<0.001], age (OR=0.964, P<0.001), and use of psycholeptic drugs (negative effect: OR=0.373, P=0.039) were the variables that contributed in general toward a change in diagnosis. Notably, the use of psycholeptic drugs seemed to impede the functional recovery in patients with DOC, so serious reflections on its use will be made.

Effects of Flexible Dry Electrode Design on Electrodermal Activity Stimulus Response Detection

OBJECTIVE

The focus of this research is to evaluate the effects of design parameters including surface area, distance between and geometry of dry flexible electrodes on electrodermal activity (EDA) stimulus response detection.

METHODS

EDA is a result of the autonomic nervous system being stimulated, which causes sweat and changes the electrical characteristics of the skin. Standard silver/silver chloride (Ag/AgCl) EDA electrodes are rigid and lack conformability in contact with skin. In this study, flexible dry Ag/AgCl EDA electrodes were fabricated on a compliant substrate, used to monitor EDA stimulus responses and compared to results simultaneously collected by rigid dry Ag/AgCl electrodes.

RESULTS

A repeatable fabrication process for flexible Ag/AgCl electrodes has been established. Surface area, distance between and geometry of electrodes are shown to affect the detectability of the EDA response and the minimum number of sweat glands to be covered by the electrodes has been estimated at 140, or more, in order to maintain functionality. The optimal flexible EDA electrode is a serpentine design with a 0.15 cm² surface area and a 0.20 cm distance with an average Pearson correlation coefficient of .

CONCLUSION

Fabrication of flexible electrodes is described and an understanding of the effects of electrode designs on the EDA stimulus response detection has been established and is potentially related to the coverage of sweat glands.

SIGNIFICANCE

This work presents a novel systematic approach to understand the effects of electrode designs on monitoring EDA which is of importance for the design of wearable EDA monitoring devices.

Right median nerve electrical stimulation for acute traumatic coma (the Asia Coma Electrical Stimulation trial): study protocol for a randomised controlled trial

Background

Traumatic brain injury (TBI) has become the most common cause of death and disability in persons between 15 and 30 years of age, and about 10–15% of patients affected by TBI will end up in a coma. Coma caused by TBI presents a significant challenge to neuroscientists. Right median nerve electrical stimulation has been reported as a simple, inexpensive, non-invasive technique to speed recovery and improve outcomes for traumatic comatose patients.

Methods/design

This multicentre, prospective, randomised (1:1) controlled trial aims to demonstrate the efficacy and safety of electrical right median nerve stimulation (RMNS) in both accelerating emergence from coma and promoting long-term outcomes. This trial aims to enrol 380 TBI comatose patients to partake in either an electrical stimulation group or a non-stimulation group. Patients assigned to the stimulation group will receive RMNS in addition to standard treatment at an amplitude of 15–20 mA with a pulse width of 300 μs at 40 Hz ON for 20 s and OFF for 40 s. The electrical treatment will last for 8 h per day for 2 weeks. The primary endpoint will be the percentage of patients regaining consciousness 6 months after injury. The secondary endpoints will be Extended Glasgow Outcome Scale, Coma Recovery Scale-Revised and Disability Rating Scale scores at 28 days, 3 months and 6 months after injury; Glasgow Coma Scale, Glasgow Coma Scale Motor Part and Full Outline of Unresponsiveness scale scores on day 1 and day 7 after enrolment and 28 days, 3 months and 6 months after injury; duration of unconsciousness and mechanical ventilation; length of intensive care unit and hospital stays; and incidence of adverse events.

Discussion

Right median nerve electrical stimulation has been used as a safe, inexpensive, non-invasive therapy for neuroresuscitation of coma patients for more than two decades, yet no trial has robustly proven the efficacy and safety of this treatment. The Asia Coma Electrical Stimulation (ACES) trial has the following novel features compared with other major RMNS trials: (1) the ACES trial is an Asian multicentre randomised controlled trial; (2) RMNS therapy starts at an early stage 7–14 days after the injury; and (3) various assessment scales are used to evaluate the condition of patients. We hope the ACES trial will lead to optimal use of right median nerve electrical treatment.

Trial registration

ClinicalTrials.gov, NCT02645578. Registered on 23 December 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2045-x) contains supplementary material, which is available to authorized users.

Special Issue on Occupational Therapy for Adults With Traumatic Brain Injury

Awareness of the incidence and consequences of traumatic brain injury (TBI) has increased in recent years, along with interest in knowing how best to treat this complex condition. This editorial provides an overview of the various factors that contribute to the complexity of TBI and introduces the six systematic reviews and one qualitative study included in this special issue of the American Journal of Occupational Therapy focusing on interventions for TBI from an occupational therapy perspective. Issues with the generation and interpretation of research evidence are discussed, along with the importance of valuing clinician expertise and client perspectives along with research findings in implementing evidence-based and evidence-informed practice.