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Multimodal Sensory Stimulation Treatment for an Individual with Chronic

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Title: Multimodal Sensory Stimulation Treatment for an Individual with Chronic


1
Multimodal Sensory Stimulation Treatment for an
Individual with Chronic Severe TBI
  • Sakina S. Drummond Melissa McDonough
  • Southeast Missouri State University
  • ASHA Convention, Chicago, IL
  • 2008

2
Introduction Sensory Stimulation
  • Sensory stimulation is a common intervention
    method for patients in coma following traumatic
    brain injury (TBI).
  • Sensory stimulation activates the limbic system
    to help generate goal-directed behaviors 1, 2.
  • Emotion-provoking stimuli enhance amygdaloid
    activity to facilitate limbic system
    activitation3, 4.
  • Benefits from sensory stimulation are boosted if
    it is delivered by persons familiar to the
    comatose patient5.

3
Multimodal Sensory Stimulation
  • Sensory stimulation can be provided through
    different modalities
  • Auditory Visual
  • Tactile Olfactory
  • Gustatory Kinesthetic
  • Vestibular Proprioceptive
  • Simultaneus use of two or modalities are
    typically referred to as multimodal stimulation.
  • Combined use of the following modalities have
    been the most efficacious 6, 7
  • Tactile auditory stimulation
  • Visual proprioceptive stimulation

4
Research Need
  • Literature supporting sensory stimulation is
    restricted to individuals recovering from acute
    TBI6, 8, 9, 10, 11.
  • Approximately 14 of TBI patients remain in
    persisting vegetative state long after discharge
    from acute rehabilitation7.
  • There is no evidence on the delivery of sensory
    stimulation to chronic individuals with TBI.
  • Systematic presentation of multimodal stimulation
    by persons familiar to the comatose individual
    remains unexamined.

5
Research Purpose Design
  • Influence of the following variables was
    determined
  • Controlled combinations of sensory stimuli
  • Emotional ties to stimuli
  • Stimulation delivery by familiar personnel
  • A longitudinal, single-subject (ABA) design was
    used
  • Pre- and post-intervention assessment (A) phases
  • Intervening delivery of multimodal stimulation
    (B) phase

6
Subject Description
  • A 23 year old Caucasian male with severe TBI from
    a fall served as the subject.
  • The onset of TBI was at age 17, five years prior
    to the study.
  • Subject was a senior in high school at that time.
  • Subject remains in vegetative state since the
    TBI.
  • Subject currently resides in a nursing home.
  • Subjects father (legal guardian) completed the
    institutionally approved Informed Consent Form.

7
Assessment Tools
  • Three assessment protocols were used
  • Glasgow Coma Scale (GCS)12
  • Ranchos Los Amigos (RLA) severity rating scale13,
    14
  • Western Neurosensory Sensory Stimulation Protocol
    (WNSSP)15
  • Each of these procedures was completed at two
    intervals
  • Prior to delivery of multimodal stimulation
  • One week following intervention.

8
Intervention Stimuli
  • Five modality pairs were used for stimulation
  • Auditory tactile
  • Auditory thermal
  • Auditory visual
  • Auditory olfactory
  • Auditory gustatory
  • Two sets of stimuli (familiar/pleasurable
    unfamiliar/aversive) were selected for each
    modality pair, resulting in 10 total sets.
  • Each stimulus pair was presented for at least 5
    seconds.
  • Each modality pair was presented in a consistent
    order.
  • Two trials of each modality pair were presented
    in each session (refer to Table).

9
Table Modality Pairs, their Presentation Order
Respective Stimuli for Each Trial
  • Modality Pair Stimuli
  • Auditory-tactile stimulation Light touch
  • Deep pressure
  • Auditory-thermal stimulation Cold washcloth
  • Warm washcloth 
  • Auditory-visual stimulation Familiar pictures
    (scrap-/yearbook/photos)
  • Unfamiliar pictures (magazine / television)
  • Auditory-olfactory stimulation Pleasant odor
    (cologne / lemon juice)  
  • Unpleasant odor (vinegar/rubbing alcohol)
    Auditory-gustatory
    stimulation Positive taste (soda/ apple juice)
  • Negative taste (lemon juice)

10
Intervention Implementers
  • 7 young adults (M age 22.3), 4 females 3 males
  • They were classmates friends.
  • None had any training in speech-language
    pathology.
  • They had a high school education were employed.
  • They received verbal written instructions
    regarding
  • Arranging equipment and positioning themselves
  • 5 modality pairs their presentation
  • Delivery of each stimulus set
  • Observing and coding elicited responses.

11
Intervention Procedures
  • Each session was videotaped and conducted in the
    subjects room.
  • The stimulation regime was provided daily, 7 days
    per week across 4 consecutive weeks (28
    sessions).
  • Each implementer delivered a session per week (4
    sessions per implementer).
  • Behaviors resulting from the delivered stimulus
    were coded for 4 possible vocal and/ or 6 motor
    responses.
  • Duration of each session was approximately 30
    minutes.

12
Results Assessment Performance
  • No significant difference was found between pre-
    and post-intervention for the 3 protocols (t
    -1.00 df 2 p.42).
  • GCS and RLA scores remained unchanged.
  • WNSSP score showed improvement by 3 points.
  • This protocol was more sensitive in detecting
    changes.

13
Results Observed Responses
  • Motor responses occurred in the following order
  • Labial movements (M 13.68)
  • Limb movements (M 11.75)
  • Increased facial tension (M 8.50)
  • Head turn/roll (M 7.29)
  • Trunk movement (M 1.32)
  • Eye opening (M .14)
  • Vocal responses increased by 4th week, and showed
    a hierarchy
  • Deep breaths/sighs (M 4.57)
  • Grunts/moans (M .93)
  • Words or phrases never occurred.

14
Results Vocal vs. Motor Responses
  • Motor responses (M 42.86 SD11.42) occurred
    more often than vocal responses (M 5.54
    SD4.87). This difference was statistically
    significant (t19.04, df27, p.00).
  • Both types of responses increased from first to
    final (4th) week.

15
Results Sensory Modalities
  • Overall high and significant correlation was
    found between auditory-thermal and
    auditory-gustatory stimulations (RHO .79 p
    .05).
  • Analysis of each stimulus type identified 20
    (44) moderate, yet statistically significant,
    correlations.
  • The majority of these correlations were for the
    following stimuli
  • Thermal (cold, warm)
  • Tactile (light touch, deep pressure)
  • Olfactory (pleasant, unpleasant odor)

16
Results Stimuli Effect
  • Gustatory positive taste was more effective.
  • Thermal cold sensation was more effective.
  • Tactile deep pressure was more effective.
  • Olfactory unpleasant odor was more effective.
  • Visual familiar picture was more effective.

17
Results Implementers
  • Seventeen (89) significant correlations were
    found between implementers in their scoring of
    observed responses (RHO gt.71, p .05).
  • Five of the implementers maintained strong
    agreement in their coding of observed responses.

18
Conclusions
  • Individuals with chronic and severe TBI can
    benefit from select forms of multimodal
    stimulation.
  • Stimulation via primitive sensory modalities
    (regulating homeostasis and survival) was the
    most effective because these modalities may be
    relatively preserved in severe TBI these sensory
    signals bypass the thalamus to directly activate
    the hippocampus and limbic system.
  • Responses are facilitated by select types of
    stimuli that tend to be relatively intense or
    potent, and rouse an emotion.

19
Conclusions (contd)
  • Motor responses are readily elicited to delivered
    stimulation.
  • Familiar, yet diverse, individuals can be
    effectively trained to deliver multimodal
    stimulation. Their involvement may facilitate
    cognitive rehabilitation in severe TBI and be
    cost effective as well.
  • Rigidity in the stimulation delivery protocol may
    have a potential drawback by not accommodating
    for implementers interaction styles.
  • Single ½ hour sessions each day may be
    insufficient to effect significant improvement
    across four-week intervention.

20
References
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  • Ito, M. (1998). Consciousness from the viewpoint
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    brain. International Journal of Psychology, 33,
    191-197.
  • Adolphs, R., Tranel, D., Buchanan, T. (2005).
    Amydala damage impairs emotional memory for gist
    but not details of complex stimuli. Nature
    Neuroscience, 8, 512-518.
  • Papps, B., Calder, A., Young, A., OCarroll, R.
    (2003). Dissociation of affective modulation of
    recollective and perceptual experience following
    amygdala damage. Journal of Neurology
    Neurosurgery and Psychiatry, 74, 253-254.
  • Lippert-Gruner, M., Wedekind, C., Klug, N.
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  • Lippert-Gruner, M., Terhaag, D. (2000).
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  • Lombardi, F., Taricco, M., De Tanti, A., Telaro,
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  • Doman, G., Wilkinson, R., Dimancescu, M.,
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  • Mitchell, S., Bradley, V., Welch, J., Britton,
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  • Wilson, S., Powell, G., Elliot, K., Thwaites,
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