This document outlines a coma stimulation program that uses sensory stimulation techniques to increase arousal and elicit movement in individuals in a coma or persistent vegetative state. It discusses the neuroanatomical basis of coma, causes of coma, principles of sensory stimulation including median nerve stimulation, and recent advances such as using warm foot baths for head trauma patients. Sessions are recommended to start at 1 hour daily and increase in duration and frequency as the patient improves.

1. COMA STIMULATION PROGRAM
- Syed Adil (MPT)

2. CONTENT
• Introduction
• Neuroanatomical basis
• Causes
• Sensory stimulation
• Median nerve stimulation
• Recent advance
• References

3. “Coma” is the prolonged state of
unconsciousness.

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

5. NEUROANATOMICAL BASIS
Consciousness is a state of awareness of self and
the environment.
Consciousness
Awareness Arousal
(content of consciousness) (level of
consciousness )

6. • Coma is caused by disordered arousal rather than
impairment of the content of consciousness
• Arousal depends on an intact ascending reticular
activating system and connections with diencephalic
structures.
• coma is caused by diffuse bilateral hemisphere damage,
failure of the ascending reticular activating system, or

7. • A unilateral hemisphere lesion will not result in coma
unless there is secondary brain stem compression,
caused by herniation, compromising the ascending
reticular activating system.

9. CAUSES
• Extensive bilateral damage or disturbance of the
hemisphere function is required to produce coma.
• Diffuse or extensive processes affecting the whole brain
• Supratentorial mass lesions causing tentorial herniation
with brain stem compression (associated with other
neurological signs such as third nerve palsy and crossed
hemiparesis)

10. • Brain stem lesions—for example, compression from
posterior fossa mass lesions such as cerebellar
haemorrhage/infarction and disorders primarily
affecting the brain stem (for example, basilar artery
thrombosis).

11. Glasgow coma scale (GCS)
• To asses the level of consciousness

13. COMA STIMULATION
• It is an intervention which uses Sensory stimulation in an
attempt to increase the Level of arousal and elicit movement
in individuals in a coma or persistent vegetative state.

14. PRINCIPLES
• Cardinal Rule - Do not harm the patient
• Check the resting vitals
• Stop immediately in case of ICP/CPP raise
• Control environmental distractions
• Organize the stimuli
• Provide distinct and well differentiated stimuli

15. • Allow extra time for the patient to respond
• Meaningful stimuli
• Verbally reinforce responses
• Try stimulating all the senses
• Identify stimuli which the patient responds to
• Include family participation

16. SENSORY STIMULATION

17. Tactile
Gustatory
olfactory
Visual
Auditory
Vestibular

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

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

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

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

22. TACTILE STIMULATION
• May be facilitatory or inhibitory. E.g., Pain and light touch to
skin produces inhibitory response/ Touch, pressure, slow
stroking of the spine produces facilitatory response
• Avoid unpleasant stimuli like pin prick, Avoid ice to face or
body as it may trigger sympathetic nervous system

23. • Use variety of textures/ variety of temperatures
(warm or cold clothes/ metal spoons dipped for 30 secs
in hot or cold water)
• Varying pressure on muscle belly and tendon, rubbing
sternum, pressing nail bed etc.

24. VESTIBULAR STIMULATION
• Fast change in position (Faster movements) tend to facilitate
arousal
• Mobility activities promote body and positional awareness
• Using Tilt table, Rocking chairs, frequent position changes in
bed
• Avoid spinning movements may trigger seizures
• Avoid mechanical inputs like sudden raising and lowering of bed

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

26. RIGHT MEDIAN NERVE STIMULATION [RMNS]
High Frequency biphasic Electrical
Stimulation
• Asymmetric biphasic pluses at an
amplitude of 15-20 mA (as tolerated)
• Pulse width of 300 us at 40 Hz ON
for 20 s and OFF for 40 s
• 8 hours per day

27. • Median nerve stimulation brings numerous afferent
inputs to the Ascending Reticular Activating System
(ARAS) via the spinoreticular component of the median
nerve synapsing with the neurons of the Ascending
Reticular Activating System.
• Median nerve stimulation seems to activate the entire
central nervous system.

28. • It is proposed that this peripheral stimulus goes to the
Ascending Reticular Activating System, which further
connects with the intra laminar nuclei of the thalamus and
then stimulates the cortical layers
• Activates projections between thalamus and cortex
• Possibly silent or injured synapses are transformed into
functional ones by neurotrophic factors

29. • Increased cerebral blood flow and enhancement of
neurotransmitter metabolism

30. RECENT ADVANCE
The effect of warm foot bath on the
consciousness of the patients with head trauma
Received : 20 June 2018
Accepted : 15 Sep 2018
Jalil Azimian, Leili Yekeh Fallah, soniya oveysi

31. References
• Lei J, et al. J Neurotrauma 2015;32:1584-89
• Maiese k, chong zz, shang yc, wang S, Targeting disease through novel
pathways of apoptosis and autophagy. Expert Opin Ther Targets 16
(12):1203–1214, 2012. doi: 10.1517/14728222.2012.719499. Epub
2012 Aug 27

32. • Wu X, Zhang Cet al., Right median nerve electrical stimulation for acute
traumatic coma (the Asia Coma Electrical Stimulation trial): study protocol
for a randomised controlled trial. Trials. 2017:18(1):311.
• Christian v. Peri, mark e. Shaffrey, elana farce: pilot study of electrical
stimulation on median nerve in comatose severe brain injured patients: 3
month outcome. Brain injury, 2001; 15(10):903-910

33. • Pape TL-B, Rosenow JM, Steiner M, Parrish T, Guernon A, Harton B, et
al. Placebo-controlled trial of familiar auditory sensory training for
acute severe traumatic brain injury: a preliminary report. Neurorehabil
Neural Repair. 2015;29(6):537–47.
• Giacino JT. Sensory stimulation: theoretical perspectives and the
evidence for effectiveness. NeuroRehabilitation. 1996;6(1):69–78
• Sensory stimulation for brain injured individuals in coma or vegetative
state2002 Apr; 2002(2): CD001427

34. Thank you