Coma stimulation techniques for Physiotherapists in handling comatose patients

1. COMA STIMULATION

2. WHAT IS COMA
• 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.
(American Congress of Rehabilitation Medicine, 1995)
Coma is a profound state of unconsciousness.

3. COMA STIMULATION
• Coma stimulation programme is an approach based on stimulating the
unconscious person’s senses of hearing, touch, smell, taste and vision
individually in order to help their recovery.
• Types: Unimodal/Multimodal
• Techniques:
Visual/Auditory/Olfactory/Gustatory/Cutaneous/Kinesthetic.

4. THEORIES OF COMA STIMULATION
• Spare capacity and reorganization: Activation of Non-
Active/Spare/Dormant areas
• The redundancy theory: Ability to duplicate neuronal pathways
• The response at a cellular level theory: Collateral sprouting to attempt
rewiring the system.
• The environmental effects theory

5. PRINCIPLES
• Cardinal Rule - Do not harm the
patient
• Check the resting vitals
• Stop immediately in case of
ICP/CPP raise
• Control environmental
distractions
• Organise the stimuli
• Provide distinct and well
differentiated stimuli
• 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
Garret, Muehhng, Morrow and Riggs (1990)

6. CRITERIA FOR ELIGIBLE PATIENTS
• Patients with acute hemorrhage, diffuse axonal injury, hypoxia or
stroke
• GCS score less than 10
• RLA score of I, II, III
• Stable vitals
• ICP of less than 15 mm hg for atleast a 24 hour period

7. COMA STIMULATION KIT

8. 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

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

10. OLFACTORY STIMULATION
• 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

11. 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.

12. 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
• Use variety of textures/ variet 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.,

13. GUSTATORY STIMULATION
• Provide taste stimulation, unless patient is prone to aspiration.
• Cotton swab dipped in sweet, salty or sour solution
• Avoid excess sweet as it induces more salivation.
• Facial grimacing is an indicator that the taste sensation is working

14. KINESTHETIC/PROPICEPTIVE/
VESTIBULAR STIMULATION
• Slow change in position tend to inhibit/ Faster movements 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

15. 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

16. RIGHT MEDIAN NERVE STIMULATION
[RMNS]
• Large cortical representation
• Peripheral port
• Spinoreticular component of median nerve
pathway
• RAS & Limbic system
• Activates projections between thalamus
and cortex
• Possibly silent or injured synapses are
transformed into functional ones by
neurotrophic factors
• Increased cerebral blood flow and
enhancement of neurotransmitter
metabolism
Lei J, et al. J Neurotrauma 2015;32:1584–89

17. RMNS - PARAMETERS
• High Frequency biphasic Electrical Stimulation
• Asymmetric biphasic pluses at an amplitude of 15–20 mA (as
tolerated)
• Pulse width of 300 μs at 40 Hz ON for 20 s and OFF for 40 s
• 8 hours per day
Wu X, Zhang C et 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.

18. THANK YOU