TVP WEEKLY: What does the process of coming out of a coma look like?

PIOTR SIWIK The term “coma” can be misleading. Most of our patients are conscious, with their eyes open, and at the same time we are unable to confirm that they are aware of their environment. They don’t react to what’s happening around them; they are unable to track with their sight. Brain injuries or their atraumatic damage, such as ischemic or hemorrhagic, can cause a lot of damage to the brain, and at the same time the loss of its various functions.

At the very beginning, we are not always able to accurately diagnose how serious the damage is. It happens that after the first tomography or magnetic resonance of the head, we can guess at how much the brain has been damaged and that the patient’s prognosis is not very good. Meanwhile, after a few months, we are shocked when they regain consciousness and return, more or less, to fitness and independence. In turn, sometimes we have the impression that the damage isn’t very serious and the patient should “hit the ground running” but their condition doesn’t improve for many months.

In the case of a lot of patients who find themselves in a coma after neurological injuries, standard rehabilitation lasting several weeks or months is insufficient. Often, the patient’s state of consciousness begins to improve after many months of systematic rehabilitation. As a result of this observation, “waking” units appeared.

As for the process itself, it’s very important to recognize, through a so-called communicator, whether the patient is in contact with the environment. In Olsztyn’s “Waking Center”, we use “cyber eyes”, that is C-Eye devices that contain an eyeball tracking system. In the past, in order to communicate with the patient, to find a common code with them, simple tables with the alphabet were used. It was very tedious. However, communication with the patient has been computerized. The C-Eye device (developed 10-15 years ago) has been widely used commercially for about 6-7 years.

What is this device?

This is a screen equipped with cameras with “eye-tracking” functionality, so, following the movement of the eyeballs. Our questions, suggestions, various words, pictograms, images and videos are displayed on it. If the patient reacts, for example by expressing emotions at the sight of an image related to his family life, we have a signal that they understand us and are conscious. Of course, we aren’t able to precisely measure the degree of consciousness, but it's a very helpful device. It is diagnostic on the one hand and therapeutic on the other.

Therapeutic, so it stimulates brain activity?

Yes, the brain controls various functions: cognitive, sensory and motor, which we can exercise. We also stimulate the brain by affecting receptors on and under the skin, as well as in tendons, muscles and fascia, for example, through special vibration platforms. How do they work?

The platform we use was originally intended for astronauts. It was supposed to help them regain fitness, fine motor movement and muscle mass, because the force of gravity to which astronauts are subject to adversely affects the skeletal and muscular system. Although it was primarily intended for able-bodied people and athletes, it can also be used (to a limited extent) in the process of coming out of a coma or for broadly-understood rehabilitation.

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  When it comes to its use, it’s attached to a verticalizing platform, which we place the patient on, and then gradually move it to an upright position. Their legs rest on the vibrating platform. Then, the appropriate frequency, amplitude, intensity and time of vibration are selected, which stimulates the locomotor and nervous systems.

What role do speech therapists play in the recovery process?

We not only communicate with patients by eye movement, but also by facial expressions. Speech therapists work with patients on this – they stimulate facial muscles.

In addition, they activate the organs responsible for swallowing and breathing, such as the mouth, tongue, throat, and larynx. Typically, such stimulation consists of manual work, and after regaining consciousness and establishing cooperation with the patient – on attempts at verbal communication.

But we also have a neuromuscular stimulation device that activates speech, swallowing and breathing. This is very important because most patients breathe unnaturally through tracheostomy tubes. Thanks to them, they breathe safely, as they protect the patient from aspiration and facilitate airway suctioning (for the same reason, most patients are fed through gastrostomy tubes – directly into the stomach).

The speech therapist also stimulates the patient’s taste stimuli by giving small amounts of food – both extremely intense and mild in terms of flavor. A reaction is triggered to taste stimuli in the glands and muscles. Speech therapy work prepares the patient for potential gastrostomy tube removal.

What about aromatherapy or music therapy?

They are also used, although not always in a highly formalized way, but often in cooperation with the families of patients. For a patient who is detached from his natural environment for many months, we provide taste, smell (these types of sensations work closely together) and auditory stimuli. For example, smells that are familiar to them from their normal environment and which are pleasant to them. If we know what music or broadcasts they listened to, then providing them with these stimuli can also cause a strong reaction.

Patients who gradually regain contact with their surroundings are only able to communicate to us that they like or dislike something, that they want something or don’t want it. So we get a simple answer, but it tells us a lot, because we can choose stimuli that the patient enjoys and to which they will adapt.

How much time does a coma patient need daily for rehabilitation?

First, we get to know the patient. They adapt to new conditions. We gradually increase the activity related to exercises and treatments – besides those I have already mentioned, we also perform hydromassages and hydro-air massages. Hydromassage can be compared to a massage in a jacuzzi for example [the patient is immersed in water – ed.]. It is pleasurable, but also stimulating.

And what does a hydro-air massage look like?

The patient is on a special rubber membrane, under which there is water [the patient has no direct contact with it – ed.]. The water, which is usually warm (the temperature can be adjusted), performs a massage in different areas, directions and with a certain intensity through the aforementioned membrane (hence the other name: membrane massage). This gives the patient a sense of comfort. Although they can also be stimulated by a more intense massage.

We divide our time into treatments and physical exercises. Treatments are supposed to relax or stimulate the patient to prepare them for exercise. Exercise, on the other hand, lasts as long as possible. Unfortunately, many patients react to brain damage with spasticity, which is increased muscle tone. Spasticity greatly limits the ability to move. It often leads muscles to contractures, which can become permanent over time.

During exercise, we try to achieve the maximum range of motion possible, which at a certain point becomes a heavy burden and even a discomfort for patients. That’s why we gradually adapt them to exercise. We fight spasticity through exercise, but also pharmacologically: by administering drugs acting generally or locally on individual muscles (in the form of botulinum injections).

How many patients are currently staying at the “Waking Center” in Olsztyn?

Fifteen. It should be noted that there are different levels of coming out of a coma. One patient responds to us with facial expressions or small movements of the limbs. There are also those who get back on their feet and leave the “Waking Center” on their own. From the moment when we find that the patient is clearly awake, we can keep them – continuing their rehabilitation – for only a month.

Further rehabilitation should take place outside the clinic, in rehabilitation units or at home – depending on the decision of the patient’s family and logistics.

You mentioned the use of modern technologies. Do they translate into the effectiveness of coming out of a coma?

The breakthrough came in communicating with patients, but not in the process of waking them up. Certainly, thanks to modern devices, such as C-Eye, we can diagnose what stimuli patients react to at a fairly early stage and how we can exercise with them while continuing therapy. This gives the possibility for specific work – directed not only at the musculoskeletal system, but also at the cognitive functions of the brain.

I hope that over time new devices will be created that will help us even more in communicating with patients. Another communication breakthrough would be the creation of a hybrid device – using not only sight, but several senses at the same time. It would be extremely helpful, especially for patients who are stuck in the recovery process and have not recovered enough to use current methods of communication.

Let’s add that attempts have already been made, including in the Department of Neurosurgery at our hospital, to directly stimulate the nervous system, the spinal cord and to improve blood circulation in the brain. Special stimulators that were implanted for this purpose have not represent the breakthrough that was expected, but they create better conditions for awakening.

There is also a rehabilitation device for patients who can’t walk on their own. It’s called Lokomat and it allows you to recreate an automated gait. One thing is certain: the more devices we can use in communicating with the patient, trying to activate their brain and the entire body, the greater the chance that we will be able to help them. At the moment, there are no universal devices.

The challenge, currently insurmountable, is to create methods for brain regeneration of places that have been damaged. But this is a thing of the future.

What role does contact with relatives and family play in coming out of a coma?

Let me give an example from two months ago. I admitted a patient that I didn’t get any reaction from during the examination. She didn’t respond to my voice, to commands to turn her head or to stimuli from the left and right side. Meanwhile, when her husband came and spoke to her – I was watching it from the side – she turned her head towards him. This shows how important emotional stimuli are for the patient in rehabilitation. Therefore, the participation of the family in the recovery process, providing not only support but also stimulation, is priceless.

– In conversation with Łukasz Lubański

TVP WEEKLY. Editorial team and journalists

–Translated by Nicholas Siekierski

Piotr Siwik is the coordinator of the Neurological Rehabilitation Department and the General Rehabilitation Department of the University Clinical Hospital in Olsztyn, the coordinator of the “Waking Center” clinic for adults and a lecturer at the Department of Neurosurgery at the Faculty of Medical Sciences of the University of Warmia and Mazury.