considerations for the use of assistive technology in patients with impaired states of consciousness
TRANSCRIPT
This article was downloaded by: [The UC Irvine Libraries]On: 19 October 2014, At: 20:44Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH,UK
NeuropsychologicalRehabilitation: An InternationalJournalPublication details, including instructions for authorsand subscription information:http://www.tandfonline.com/loi/pnrh20
Considerations for the useof assistive technology inpatients with impaired states ofconsciousnessKaren Naudé & Matthew Hughesa Royal Hospital for Neuro-disability , London, UKPublished online: 11 Jan 2007.
To cite this article: Karen Naudé & Matthew Hughes (2005) Considerations forthe use of assistive technology in patients with impaired states of consciousness,Neuropsychological Rehabilitation: An International Journal, 15:3-4, 514-521
To link to this article: http://dx.doi.org/10.1080/09602010443000470
PLEASE SCROLL DOWN FOR ARTICLE
Taylor & Francis makes every effort to ensure the accuracy of all theinformation (the “Content”) contained in the publications on our platform.However, Taylor & Francis, our agents, and our licensors make norepresentations or warranties whatsoever as to the accuracy, completeness, orsuitability for any purpose of the Content. Any opinions and views expressedin this publication are the opinions and views of the authors, and are not theviews of or endorsed by Taylor & Francis. The accuracy of the Content shouldnot be relied upon and should be independently verified with primary sourcesof information. Taylor and Francis shall not be liable for any losses, actions,claims, proceedings, demands, costs, expenses, damages, and other liabilitieswhatsoever or howsoever caused arising directly or indirectly in connectionwith, in relation to or arising out of the use of the Content.
This article may be used for research, teaching, and private study purposes.Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expresslyforbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
Dow
nloa
ded
by [
The
UC
Irv
ine
Lib
rari
es]
at 2
0:44
19
Oct
ober
201
4
Considerations for the use of assistive technology in
patients with impaired states of consciousness
Karen Naude and Matthew Hughes
Royal Hospital for Neuro-disability, London, UK
While there is limited literature addressing the application of assistive technologyin patients in persistent vegetative state (PVS) and minimally conscious state(MCS), it is believed that it can assist with the assessment, diagnosis and treat-ment as well as management of these patients. The use of technology to assist inPVS and MCS is mostly limited to the application of simple binary switchdevices to determine whether a motor response is consistent or otherwise.However, the application of such technology is often undermined due to alack of established protocols for use by the multidisciplinary team (MDT), aswell as a lack of available technical resources. Therefore the ongoing develop-ment of assessment instruments as well as effective outcome measures used byan MDT is imperative. This article aims to discuss some key aspects to considerin the use of assistive technology when assessing and treating people inimpaired conscious states. Possible considerations and suggestions will bediscussed through this paper and a case study will be used to demonstratesome of these interventions.
It has been argued that advancing medical technologies and associated meansof sustaining life have led to a greater proportion of brain-injured peoplesurviving and hence requiring long-term intervention despite significantdisability (Piguet, King, & Harrison, 1999). Some of these patients presentas minimally conscious, which is a relatively new diagnostic classificationin the spectrum of consciousness disorders following the Multi-SocietyTask Force on PVS (Giacino & Kalmar, 1997). This classification is
Correspondence should be sent to Karen Naude, Department of Occupational Therapy, Royal
Hospital for Neuro-disability, West Hill, Putney, London SW15 3SW, UK. Tel: 020 8946 1472.
Email: [email protected]
NEUROPSYCHOLOGICAL REHABILITATION
2005, 15 (3/4), 514–521
# 2005 Psychology Press Ltd
http://www.tandf.co.uk/journals/pp/09602011.html DOI:10.1080/09602010443000470
Dow
nloa
ded
by [
The
UC
Irv
ine
Lib
rari
es]
at 2
0:44
19
Oct
ober
201
4
proving especially beneficial in the diagnosis and management of patients, inparticular by distinguishing between PVS and MCS. This is a condition ofseverely altered consciousness in which the person demonstrates minimalbut definite evidence of self or environmental awareness. Historically it hasbeen speculated that such patients may have some internal awareness butno ability to demonstrate it as such. However, despite the development of adiagnostic classification there are difficulties with its successful application,primarily due to the very nature of the clinical features, namely the inconsist-ent response style of these patients and often severe motor and sensoryimpairments, making assessment somewhat complex.
Despite the complexity of these patients, several standardised assessmentmeasures (O’Dell, Jasin, Lyons, Stivers, & Meszaros, 1996) have been devel-oped to assess the potential transition between states of consciousness. Theseinclude the Western Neuro Sensory Stimulation Profile (Ansell & Keenan,1989), the Coma Near Coma Scale (Rappaport, Doughtery, & Kelting,1992), and the Sensory Stimulation Assessment Measure (Rader & Ellis,1994). Additional measures such as the Sensory Modality Assessment andRehabilitation Technique (SMART; Gill-Thwaites & Munday, 1999), andthe Wessex Head Injury Matrix (Shiel et al., 2000) highlight the importanceof collaborative work within the MDT, in order to record any behaviouralchanges that may influence the “level” of the intervention (Canedo, Grix,& Nicoletti, 2002). Some of these instruments go on to suggest treatmentinterventions, which are based on sensory stimulation, although this is notconclusively supported in the literature. The SMART, however, suggeststhe use of a buzzer to determine a person’s ability to respond to auditorystimuli and follow verbal commands by eliciting a purposeful movement.This is possibly one of the only examples of the use of assistive technologyto help with assessment and treatment intervention.
Assistive technology encompasses any device used to demonstrate,increase, maintain, or improve interaction and functional capabilities of indi-viduals with disabilities. Assistive technology solutions improve an individ-ual’s ability to learn, compete, work, interact with family and friends, achievegreater independence, and enjoy a better quality of life. Therefore, areas toconsider for the use of assistive technology, such as simple binary switches,include assessment and diagnosis, family involvement, communication andapplication.
ASSESSMENT AND DIAGNOSIS
Switch use has been successfully applied in the identification of misdiagnosisdue to visual deficits (Andrews, Murphy, Munday, & Littlewood, 1996),neuropsychological assessment of a potential “euthanasia” case (McMillan,
ASSISTIVE TECHNOLOGY IN PVS AND MCS 515
Dow
nloa
ded
by [
The
UC
Irv
ine
Lib
rari
es]
at 2
0:44
19
Oct
ober
201
4
1996; McMillan & Herbert, 2000), and a lack of potential for further recovery(Watson, Horn, & Wilson, 1999). Switch use is also suggested in assessmentand treatment protocols such as the SMART (Gill-Thwaites, 1997). Success-ful use may lead to functional implications for the individual, such as thepossibility of controlling the environment or facilitating basiccommunication.
FAMILY
Family involvement and adjustment to change has been sighted as an integralpart of treating a patient with a severe head injury (Kreutzer, Kolakowsky-Hayner, Demn, & Mead, 2002). One way in which families interact withpatients demonstrating inconsistent responses in MCS is through the useof low level technological interventions, such as a plate switch connectedto a latched timer to operate an electronic device. In exceptional circum-stances more advanced, and often custom made switches, including blinkand muscle activated switches, are considered for patients with verylimited motor ability. These switches can additionally be used to accessfurther integrated systems such as those used to facilitate both communicationand mobility needs concurrently.
COMMUNICATION
The use of assistive technology has greater potential application in thosepatients who progress beyond the MCS. A single switch or buzzer can beused to express an established yes/no response, develop a simple communi-cation system to express basic needs, or even assist in determining mentalcapacity. This may be done either through the use of a scanning device orby activating switches directly. The provision of technology at this stagecan consequently facilitate the use of environmental controls, powered mobi-lity, and complex communication devices known as augmentative alternativecommunication (AAC). Currently, the use of these communication aids toassist with memory impairment in complex disability remains an explorativetopic for further research.
FURTHER CONSIDERATIONS AND APPLICATION
Although establishing a person’s ability to elicit a motor movement isessential, it is also important to be aware of the factors affecting the use ofa single switch. Angelo (2000), completed a study in which she identified11 considerations that therapists regarded as important for switch access.
516 NAUDE AND HUGHES
Dow
nloa
ded
by [
The
UC
Irv
ine
Lib
rari
es]
at 2
0:44
19
Oct
ober
201
4
Some of these include the reliability of motor movement, endurance andability to perform timed response, hence, highlighting the complex natureof such interventions.
Environmental adaptations are also important to compensate for patients’limited and restricted movement due to their impairment in neuromotorsystems (Gentile, 1998). Therefore, appropriate posture and seating andaccurate mounting of devices are required to ensure matches between theenvironment and motor ability of the patient (Gentile, 1998).
Much work has been done by Cook and Hussey (2002) regarding theinterdisciplinary approach and the effectiveness of the use of technologywith patients with severe disability. They adapted the model used byBailey (1989) to define the application of assistive technology. The HumanActivity Assistive Technology (HAAT) model focuses on the interaction ofthe human/technology interface, the activity output, and the environmentalinterface when determining the appropriate use of assistive technology.This, however, has not necessarily been generalised to the population ofMCS and PVS patients.
Some specialist neurorehabilitation units have technology clinics where avariety of the approaches described above are used. Where appropriate, thesemodels need to be considered to develop an effective assistive technologyservice. One such example is the technology clinic at the Royal Hospitalfor Neuro-disability, London, UK.
In this clinic a systematic approach is followed to establish the potentialfor the use of assistive technology, which includes a variety of assessmentcriteria such as sensory abilities, posture, and seating and motor function.These clinics are ideally run by an interdisciplinary team to ensure apatient’s problems are holistically identified and their needs analysed toguarantee a cohesive multi-sensory and collaborative approach to therapeuticintervention.
The following case of Mr M is used to demonstrate the successfulapplication of some of the above considerations.
CASE STUDY
Mr M is in his 20s and sustained a severe closed head injury as a result of ahigh speed single vehicle collision. His initial Glasgow Coma Scale (GCS)score was 3/15. A cerebral computed tomography scan was reported toreveal diffuse cerebral damage; a subarachnoid haemorrhage, blood in hisright ventricle, diffuse cerebral oedema, multiple haemorrhages, and contu-sions, specifically in the frontal and parietal regions. His right pupil remaineddilated and non-reactive, he spent three weeks in ITU and his GCS scoreremained 3/15 although more spontaneous eye opening was noted at approxi-mately 25 days.
ASSISTIVE TECHNOLOGY IN PVS AND MCS 517
Dow
nloa
ded
by [
The
UC
Irv
ine
Lib
rari
es]
at 2
0:44
19
Oct
ober
201
4
He was subsequently admitted to the Royal Hospital for Neuro-disability70 days post-injury. On admission it was evident that he had severe physicalmanagement issues that needed to be addressed. In particular he presentedwith severe increased tone throughout, flexed neck and no active movementin his limbs. Physical management included upper and lower limb serialcasting, medication for tone management, and complex postural assessmentincluding bed and wheelchair positioning. He remained nil by mouth, wasPercutaneous Endoscopic Gastrostomy (PEG) fed and decannulationcommenced 120 days post-injury.
Mr M was assessed over four weeks, between days 80–115, using theSMART. The assessment was complicated by complex physical managementissues and pyrexia. The overall impression from the SMART indicated thatMr M was functioning on a
. Reflex level (level 2) for visual, motor and tactile stimuli.
. Withdrawal level (level 3) for auditory stimuli.
. Optimal arousal level (level 5) for wakefulness, which suggested that hecould have some underlying awareness but expression of this waslimited by his physical problems.
A multi-modal SMART sensory treatment programme was (Gill-Thwaites& Munday, 1999) commenced on day 120 and focused on visual and auditorymodalities based on the assessment results and behavioural observations. Theoverall aim was to provide modulated sensory stimulation in a structured way,in order to improve eye and head control, as well as consistency andreliability of localising to stimuli. Localisation to stimuli was measured aseither eye gaze or head movement towards stimuli.
The visual modality consisted of use of familiar visual stimuli (photos ofrally cars, family and girlfriend, and mechanical tools) and unfamiliar stimuli(colour cards) with the objective of establishing a consistent localising andtracking response (SMART level 4) in all visual fields.
The auditory modality incorporated familiar auditory stimuli (favouritemusic, voice of therapist, voice of family members) to achieve consistentlocalising to the left and right, observing gaze or head movement (SMARTlevel 4).
Treatment sessions continued from day 120 to day 150. He continued toexperience severe increased tone; however, purposeful movement and hislevel of awareness remained questionable. His eye movements to visualand auditory stimuli were uncontrolled and inconsistent and his arousallevels fluctuated and were often low. At this time the team considered thebenefits of increasing his tone medication and the associated effect thiswould have on his level of arousal versus the benefits of improved physical
518 NAUDE AND HUGHES
Dow
nloa
ded
by [
The
UC
Irv
ine
Lib
rari
es]
at 2
0:44
19
Oct
ober
201
4
management. His legs underwent serial casting and despite using removableelbow casts he was losing range at his wrists, which became more flexed.
He started showing improved responses around day 160. He turnedhis head in response to auditory and visual stimuli in all visual fields,and demonstrated improved head control, lifting it to command on severaloccasions. His eye movement was more sustained and controlled andarousal levels were often optimal during sessions. Due to improved responses,differentiating exercises were introduced into the sensory programme. Theaim was to assess the potential to use eye gaze responses to express achoice or preference. Pictures, colour cards and yes/no words were usedand visual gaze following a verbal command was observed. Verbal com-mands were introduced to improve consistency of simple motor responses,e.g., “raise your eyebrows”, “move your finger”, etc. Facilitated movementof his head, left index finger and thumb was used to assess his ability tocarry over motor control in order to press a switch to command. Feedbackfrom the MDT and Mr M’s mother regarding his behaviour was very import-ant at this stage, in particular as consistency of purposeful responses coulddetermine he had progressed from MCS and had the potential to interactmore purposefully with his environment.
Switch work progressed and at day 210 goals changed to establish Mr M’sability to follow motor commands using a switch and to move his left indexfinger and thumb, as well as his head. Several different switches were trialedincluding a Toby Churchill switch, a small plate switch and a micro-liteswitch from Toby Churchill Ltd, 20 Panton St, Cambridge CB2 1HP.
Consequently, a single switch was positioned in his left hand, between hisleft index finger and the dorsal aspect of his thumb, and connected to a radioand a latched timer. Mr M was instructed to press the switch to make hismusic play. Should he do this, it would only play for 20 seconds and thenhe had to press the switch again for the music to continue. The aim of thisintervention was to establish his understanding of cause and effect relation-ships. This is the stage where assistive technology would be appropriate forpatients in low awareness states. Should the use of low technology aidssuch as those described above be successful, it would indicate that theindividual is no longer in a low awareness state, and may have the potentialto access more complex assistive technology such as environmental controls.It is important to note that the technology is not used in isolation to diagnosesuch patients but to assist them to access their residual function after a severeinjury.
In the case of Mr M, the auditory and visual treatment interventions weresuccessful and by day 240 following correct hand positioning he was able toactivate a radio using a single switch. Treatment progressed to sessions in thespecialised computer therapy room, which focused on his ability to furtherconceptualise cause and effect using a microlite switch to participate in
ASSISTIVE TECHNOLOGY IN PVS AND MCS 519
Dow
nloa
ded
by [
The
UC
Irv
ine
Lib
rari
es]
at 2
0:44
19
Oct
ober
201
4
target shooting games on the computer and looking at familiar photos on apower point presentation. Mr M was subsequently referred to the hospital-based technology clinic for further assessment and integration of assistivedevices and he continues to progress in his interaction with the environmentand use of assistive technology.
CONCLUSION
To date there have been limited studies reporting the use of assistive technologyin patients in low awareness states. However, there is scope for the use ofbinary switches to assist with the assessment and management of patientsin low awareness states. The literature offers valuable insights highlightingthe factors affecting the use of a single switch (Angelo, 2000), models thatlook at movement classification namely the skills acquisition model(Gentile, 1997) and models that describe how assistive technology impactsthe end-user such as that of HAAT (Cook & Hussey, 2002), all of whichare important to consider when using assistive technology.
While recommendations for the management of patients in PVS and MCShave been developed (Royal College of Physicians, 2003), there are currentlyno standards of care to guide the selection of rehabilitation assessments andtreatment procedures for patients with disorders of consciousness (Giacino& Trott, 2004), let alone the development of protocols for the use of assistivetechnology with PVS or MCS patients. However, the case study presenteddemonstrates the use of assistive technology and in particular how the appli-cation of switches assisted in the identification of consistent levels ofresponses and hence the emergence from MCS.
REFERENCES
Andrews, K., Murphy, L., Munday, R., & Littlewood, C. (1996). Misdiagnosis of the vegetative
state: Retrospective study in a rehabilitation unit. British Medical Journal, 313, 13–16.
Angelo, J. (2000). Factors affecting the use of a single switch with assistive technology devices.
Journal of Rehabilitation Research and Development, 37, 591–598.
Ansell, B. J., & Keenan, J. E. (1989). The Western Neuro Sensory Stimulation Profile: Tool
for assessing slow-to-recover head injured patients. Archives of Physical Medicine and
Rehabilitation, 70, 104–108.
Bailey, W. R. (1989). Human performance engineering: Using human factors/ergonomics to
achieve computer system usability (2nd ed.). Englewood Cliffs, NJ: Prentice Hall.
Canedo, A., Grix, M. C., & Nicoletti, J. (2002). An analysis of assessment instruments for the
minimally responsive patient (MRP): Clinical observations. Brain Injury, 16, 453–461.
Cook, A. M., & Hussey, S. M. (2002). Assistive technologies, principles and practice (2nd ed.).
St. Louis, MO: Mosby Inc.
520 NAUDE AND HUGHES
Dow
nloa
ded
by [
The
UC
Irv
ine
Lib
rari
es]
at 2
0:44
19
Oct
ober
201
4
Gentile, A. M. (1997). Skills acquisition: Action, movement and neuromotor processes. In
J. Carr & R. Shepherd (Ed.), Movement science: Foundations for physical therapy in
rehabilitation. Rockville, MD: Aspen.
Gentile, A. M. (1998). Implicit and explicit processes during acquisition of functional skills.
Scandinavian Journal of Occupational Therapy, 5, 7–16.
Giacino, J. T., & Kalmar, K. (1997). The vegetative and minimally conscious states: A compari-
son of clinical features and functional outcome. Journal for Head Trauma Rehabilitation,
12, 36–51.
Giacino, J. T., & Trott, C. T. (2004). Rehabilitative management of patients with disorders of
consciousness. Journal of Head Injury Trauma, 19, 254–265.
Gill-Thwaites, H. (1997). The Sensory Modality Assessment and Rehabilitation Technique: A
tool for the assessment and treatment of patients with severe brain damage in a vegetative
state. Brain Injury, 11, 723–734.
Gill-Thwaites, H., & Munday, R. (1999). The sensory modality assessment and rehabilitation
technique (SMART): A comprehensive and integrated assessment and treatment protocol
for the vegetative state and minimally responsive patient. Neuropsychological Rehabilita-
tion, 9, 305–320.
Kruetzer, J. S., Kolakowsky-Hayner, S. A., Demn, S. R., & Meade, M. A. (2002). A structured
approach to family intervention after brain injury. Journal of Head Trauma Rehabilitation,
17, 349–364.
McMillan, T. M. (1996). Neuropsychological assessment after extremely severe head injury in a
case of life and death. Brain Injury, 11, 483–490.
McMillan, T. M., & Herbert, C. M. (2000). Neuropsychological assessment of a potential
“euthanasia” case: A 5 year follow up. Brain Injury, 14, 197–203.
O’Dell, M. W., Jasin, P., Lyons, N., Stivers, M., & Meszaros, F. (1996). Standardised assess-
ment instruments for minimally-responsive, brain-injured patients. NeuroRehabilitation,
6, 45–55.
Piguet, O., King, A. C., & Harrison, D. P. (1999). Assessment of minimally responsive patients:
Clinical difficulties of single-case design. Brain Injury, 13, 829–837.
Rader, M. A., & Ellis, D. E. (1994). The sensory stimulation assessment measure (SSAM): A
tool for elderly evaluation of severely brain-injured patients. Brain Injury, 8, 309–321.
Rappaport, M., Doughtery, A. M., & Kelting, D. L. (1992). Evaluation of coma and vegetative
state. Archives of Physical Medicine and Rehabilitation, 72, 628–634.
Royal College of Physicians (2003). The vegetative state: Guidance on diagnosis and manage-
ment. London: Royal College of Physicians.
Shiel, A., Horn, S. A., Wilson, B. A., Watson, M. J., Campbell, M. J., & McLellan, D. L. (2000).
The Wessex Head Injury Matrix (WHIM) main scale: A preliminary report on a scale to
assess and monitor patient recovery after severe head injury. Clinical Rehabilitation, 14,
408–416.
Watson, M., Horn, S., & Wilson, B. (1999). Assessing a minimally responsive brain injuries
person. British Journal of Therapy and Rehabilitation, 6, 436–441.
ASSISTIVE TECHNOLOGY IN PVS AND MCS 521
Dow
nloa
ded
by [
The
UC
Irv
ine
Lib
rari
es]
at 2
0:44
19
Oct
ober
201
4