OT Treatment Ideas: Disorders of Consciousness

Prior to initiating treatment, be sure to position and set the patient up for success. If your patient is falling over in the bed with their arm pinned between their body and side rail, they will have a very hard time trying to move to command or purposefully use that extremity. Make sure your patient is positioned well with their arms “free” so they have the potential to access their environment, stimuli are limited, and their faces cleaned/mouths suctioned as needed prior to starting treatment. Included below are some general guidelines for incorporating sensory stimulation techniques. It may also be beneficial to incorporate aspects of the Coma Recovery Scale into your treatment for this patient population to more objectively track change and progress.

*Be sure to be aware of and assess for Confounders to Consciousness and Assessment

Suggested Interventions include, but are not limited to:

  • PROM and/or splinting to reduce contractures

  • Performing sensory stimulation

  • Educating family on interventions and rationale

Be sure to:

  • Inform the patient before performing any intervention

  • Speak positively in the presence of a comatose patient

Sensory Stimulation

(Cluck & Otr, 2015; Padilla & Domina, 2016)

Sensory stimulation is used to improve arousal and awareness. Research suggests that bimodal (i.e., auditory and tactile) or multimodal (i.e., all five senses) strategies impact attention and cognition. Start sensory stimulation early and frequently (i.e. 3-5 times/day for 20-minute sessions), until more complex task participation is possible (Padilla & Domina, 2016). Multimodal cues paired with action/initiation cues may increase the level of consciousness and environmental awareness  (Padilla & Domina, 2016). It is important to determine which sensory stimulation the patient responds to best and use that to facilitate arousal at the start of treatment. The CRS-R or other similar assessments can be used to track progress and guide treatment. Focus early on: primarily sensory, neuro re-education, and prevention of contracture or confounders through sensory stim, ROM/positioning, and mobilization. With OT specifically focusing on preparatory activities with progression to ADL. The overall goal is to stimulate the neural recovery process to:

  • Increase arousal and attention to allow the patient to perceive incoming stimuli

  • Improve quantity and quality of responses

  • Provide opportunities for the patient to respond to the environment

  • Heighten patient’s responses to sensory stimuli and eventually channel them into meaningful activity

Guidelines for Providing Sensory Stimulation

(Cluck & Otr, 2015)

  • Make sure the patient is comfortable and eliminate distractions

  • Allow extra time for the patient to respond

  • Keep sessions short, but frequent (15-30 min) alternating periods of stimulation with rest

  • Less aroused patients may require more intense/general stimulation at first, which can be downgraded and more specific as arousal improves

  • To improve quality/quantity of responses as arousal/responsiveness increases, direct treatment toward increasing frequency and rate, period of time patient is alert/engaged, vary responses, and quality of attention to the environment.

  • Stimulate all senses and select meaningful stimuli

  • Involve family/friends into the program

    • Faster movement tends to facilitate arousal

    • Use meaningful and familiar position changes

    • Avoid spinning (may trigger seizures)

    • Watch for early protective or delayed balance reactions

    • Monitor patients BP

    Activity Ideas

    Vestibular

    • Transfers: rolling in bed, bed mobility

    Proprioception & Kinesthetic Activities

    • Weightbearing & joint compression

    • Facilitate normal alignment

    • ROM activities

    • Positional changes

    • Tilt table

    • Side-lying

    • Only allow 1 person to speak at a time

    • Assess patient’s ability to localize sound and where it’s coming from

    • Then assess response when the location of sound changes

    • Auditory stimulation is more effective if the voice is familiar (i.e. family member) (Padilla & Domina, 2016)

    Activity Ideas

    • Verbal communication (calling the patient’s name)

    • Familiar songs/music/TV shows

    • Clapping your hands

    • Ring a bell, Whistle

    • Can be faciliatory or inhibitory

    • The face (lips and mouth) are the most sensitive

    • Use noxious stimuli (i.e., pinprick) with caution.

    • Avoid ice to face/body (may trigger sympathetic nervous system response)

    • Vary degree of pressure (firm pressure vs. light touch)

    Activity Ideas

    • Sternal rub

    • Variety of textures: clothing, blankets, stuffed animals, lotion

    • Variety of temperatures: hot/cold, metal spoon dipped in hot or cold water x30 seconds

    • Avoid touching the skin with the scent

    • Provide stimulation for 10 seconds

    • The olfactory nerve is the most commonly injured cranial nerve after TBI

    • The exchange of air through nostrils is eliminated when trached, thereby inhibiting the sense of smell

    • Nasogastric tubes can block the sense of smell

    Activity Ideas

    • Pleasant odors: aftershave, perfume, coffee grinds, favorite foods

    • Noxious odors: garlic, mustard.

      • *avoid vinegar & ammonia can irritate trigeminal N.

    • Provide stimulation to lips and area around the mouth

    • If the patient is defensive to touch (i.e., pursing lips, closing mouth, or pulling away) gently continue stimulation techniques to decrease defensive reactions and increase level of awareness

    • Be aware of diet and bite reflexes

    Activity Ideas

    • Pleasant vs sour: cotton swab in sweet, salty, or sour solution

      • Avoid sweet if the patient is having difficulty managing sections

    • Oral stimulation during mouth care

    • Provide normal visual orientation

    • Eliminate distractions

    • Attempt visual tracking after fixation is established

    Activity Ideas

    • Tracking objects: colored light/pen, familiar faces/objects, photos of family members, self in mirror

    • Scanning

    • Visual threat

Examples of Positive and Negative Response to Coma Sensory Stimulation

(Hamby, 2017)

Positive Responses

  • Blinking

  • Calming effect

  • Crying

  • Direct response to stimulus (pushing stimulus away or attending to it)

  • Eye-opening

  • Following commands

  • Grimacing

  • Increased arousal

  • Increased movement

  • Increased muscle tone

  • Respiration rate increases, then decreases

  • Swallowing

  • Vocal utterances (i.e., moaning)

Negative Responses

  • Absence of any response

  • Agitation

  • Yawning

  • Bite reflex or tightly pursed lips

  • Flushing

  • Increased salivation

  • Perspiration

  • Seizure activity

  • Startle response followed by posturing

  • Sudden decrease in arousal

  • Sustained increase in heart rate, respiration rate, &/or intracranial pressure

References

Cluck, J., & Otr, M. M. (2015, June 29). Activities for stimulation of persons with low arousal. http://s3.amazonaws.com/arena-attachments/715662/060c23188c291627d8f659d068607996.pdf?1474669884

Hamby, J. (2017). The Nervous System. In H. Smith-Gabai & S. E. Holm (Eds.), Occupational Therapy in Acute Care (2nd ed.). AOTA Press. https://library.aota.org/OT_in_Acute_Care_2e/134?highlightText=intensive%20care%20unit

Holm, S. (2017). Early Mobility and Rehabilitation. In H. Smith-Gabai & S. E. Holm (Eds.), Occupational Therapy in Acute Care (2nd ed., pp. 663–672). AOTA Press. https://library.aota.org/OT_in_Acute_Care_2e/134?highlightText=intensive%20care%20unit

Padilla, R., & Domina, A. (2016). 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. The American Journal of Occupational Therapy, 70(3), 7003180030p1-7003180030p8. https://doi.org/10.5014/ajot.2016.021022