State of consciousness at the beginning and end of PEM

The majority started MSP in a Vegetative State (63.64%), followed by patients in coma (27.27%) and finally a minority in MSC (9.09%). In the last MSP session, no patient remained in coma, 31.82% presented with CME, 59.09% with vegetative state (VS) and 9.09% progressed to a state of confusion (Graphic 1).

Graphic 1 Distribution of patients according to the State of Conscience at the Beginning and End of the MSP 

By analyzing the evolution of each patient, we found that of the 6 in coma, all evolved, 4 of them after only 1 to 4 sessions and the rest in 8 to 11 sessions. Five evolved to the VS and one surpassed the MSC (went to the state of confusion). Of the 14 who started PEM in VS, five evolved to CME in 2 to 8 sessions, one to a state of confusion, and 8 kept the VS. The 2 patients who started with MSC maintained this status.

Glasgow score at the beginning and end of the MSP

The level of awareness on the Glasgow Coma Scale at the beginning of the MSP ranged between score 3 and 9, with a mean of 7. While at the end of the MSP it ranged between score 5 and 14, with a mean of 9. Most of the patients started the MSP with Score 7 or lower (63.64%). At the end of the MSP, most had a score equal to or greater than 8 (77.27%) (Graphic 2).

For each patient, eight of them did not evolve and in the remaining 14 (63.64%) the evolution was 1 to 8 values with an average of 2.32.

Graphic 2 Distribution of patients by Glasgow Score at the beginning and end of the MSP 

LCFS level at the beginning and end of MSP

The vast majority of patients (86.36%) started MSP at level II of the LCFS and the rest (13.64%) started at level I. At the end of MSP, none remained at level I, just over half (59, 09%) stayed in level II, 27.27% stayed in level III and 13.63% went beyond level III and left the program (Graphic 3).

Graph 3 Distribution of patients by LCFS level, at the beginning and at the end of the MSP 

In the evolution of each patient, of the three patients who started MSP at level I of the LCFS, two progressed to level II and one to III. Of the 19 who started at level II, 10 remained at that level, 6 progressed to level III and 3 surpassed the latter. In total 54, 55% evolved.

Family involvement

The family of 55% of patients was actively involved in MSP. In these, the evolution in the GCS was in average 3.75 points, while in the others the evolution was an average of 0.6 points, that is, 6.25 more.

Behavioral reactions observed in the MSP application

We also registered different reactions to the applied stimulus. We highlight the power of the olfactory stimulus, even in patients in coma and VS, triggering chewing movements, eyelids (blinking, eyes widening), facial/grimaces, head, limbs and hyperventilation. We found that the reactivity to the olfactory stimulus decreased as the patient evolved in his state of consciousness. Upon gustatory stimulation, 14 patients, including those in coma, triggered chewing movements. To visual stimulus the observed reactions, including visual fixation and following stimulus, occurred in 4 patients in CME. and one in VS. 4 CME patients responded to verbal auditory stimulation with blinking and blinking, 2 coma patients responded with tears. One of the MSC patients moved all 4 limbs when seated (vestibular stimulus).

Further gains in functional independence

As already mentioned, in most cases the MSP was interrupted by patient transfer. All needed continuity of rehabilitation nursing care, namely and for this case, cognitive. The question arose as to how far they had progressed. So we went on, as far as possible, along its path. We highlight 3 cases that we know had gains in functional independence, which gives us encouragement to continue investing with our MSP, in these patients with serious neurological sequelae, as a starting point for their continued rehabilitation.

Case 1 - MLCA, female, 76 years old, hemorrhagic stroke due to aneurysm rupture. She started MSP in ICU, with mechanical ventilation, in a coma, GS 7, level I of the LCFS. Patient had 16 sessions, at the end of which she had SG 11 and LCFS level III, evolving to a state of confusion (GS 14). The two daughters were guided by us and actively involved in stimulation. From the observed reactions, we highlight the movement of the right upper limb (healthy side) to the olfactory stimulus, when in VS. She was transferred to another service, then to National Network of Continuous Integrated Care and finally to the Center for Physical Medicine and Rehabilitation (CMFR) in Alcoitão. According to data from the last neurosurgery appointment, patient lives with a daughter, has autonomous walking and some disorientation.

Case 2 - EMLF, female, 46 years old, hemorrhagic stroke due to aneurysm rupture. Patient started MSP in ICU, with mechanical ventilation, in a vegetative state, GS 6, LCFS level II. Patient had 9 sessions, at the end of which she had GS 12 (tracheostomized). The husband was very present and involved in the stimulation under our guidance. From the observed reactions, we highlight chewing movements to the taste stimulation of coffee in VS. Patient progressed even during hospitalization to GS 15 and started Activities of daily living (ADL) training. She was transferred to National Network of Continuous Integrated Care. We found, after the last neurosurgery consultation, living with her husband, presenting autonomous walking, being aware, oriented and independent in the ADL. As a curiosity, the patient, after being asked if she remembered any intervention by the MSP, said that currently couldn't even smell the coffee (Knowing patient appreciated it before) and that patient remembered some lights associating to Christmas lights (optical fibres).

Case 3 - RMFB, male, 21 years-old, severe TBI, started the MSP in Intermediate Care, in MSC, GS 9, level II of the LCFS. Patient had 28 sessions, evolving to GS 12, LCFS level III, maintaining the MSC. The mother was always present and very involved in the stimulation under our guidance. From the observed reactions, we highlight in chronological order: chewing movements to the olfactory stimulus, following with the eyes, moving the 4 limbs when sitting, turning the head to the side of the sound, response with blinking of the eyes, emission of guttural sounds in response to the stimulus verbal. Patient was transferred to the RNCCI and then to the Physical Medicine and Rehabilitation Center of S. Braz de Alportel. After the last neurosurgery consultation, we found that patient was living with his mother, had GS of 15, was walking in a wheelchair (patient reported being able to walk, although unstable, with support), presented with dysarthria and was undergoing oral feeding training, but still with Percutaneous Endoscopic Gastrostomy (PEG).

MSP application

As for the structuring of our MSP, we considered it adequate, triggering some positive behavioral reactions and we did not observe undesirable reactions, as can occur in situations of sensory overload. In particular, we did not find adverse hemodynamic changes or autonomic dysfunctions. The RCP Guidelines⁵, in line with our program, state that in these patients, overstimulation and many stimulus must be avoided simultaneously, not to trigger sympathetic hyperactivity. They recommend that stimulation should focus on pleasant sensations (favorite music, gentle massage, pets) offered one at a time, for short periods, to minimize sensory overload. And they report that although the studies are not conclusive yet, due essentially to its methodology, controlled stimulation provides the best opportunity to observe responses.

As for our concern with sensory regulation, the data obtained in the study by Pinto¹⁴, through interviews with TBI patients who had been in a coma, also lead her to consider the regulation of cognitive stimulation as important, preferably with an emotional tone.

Tayler ⁸, neuroscientist, reported in the first person his recovery from a severe hemorrhagic stroke. She refers to the importance of various sensory stimulous combined with family monitoring and alerts for their sensory regulation, with an emphasis on the serenity of the environment and communication, on the need for well-deserved rest after rehabilitation. All these aspects are also included in our MSP.

According to the study by Sun et al.,¹⁵, the use of personalized objects seems to be more effective in triggering responses in patients with alterations in the state of conscious, compared to the use of non-personal objects, in the evaluation of the item “Use of Functional Objects” of the CRS-R scale, the difference being statistically significant. It was also our concern to integrate personal items in MSP.

In another study, by Laureys et al.,¹⁶, it was found that using the patient's name, in relation to the use of other sound stimulus, causes a broader activation at the brain level when using Positron Emission Tomography (PET).

Sharon¹⁷ studied the patient's reaction in VS to familiar faces through functional MRI. The author found that the activated regions were those related to emotional activities in the limbic area. This study showed that familiar stimulus, such as familiar faces, result in a greater number of responses.

The study by Heine et al.,¹⁸ concluded that favorite music and familiar voices have effects on these patients' cognitive and behavioral processes.

We found that in our MSP, the aspects referred to in these studies are covered there.

We also found that some studies focus more on the diagnostic assessment of the state of conscious, for clinical decision-making (for example, in the case of insurance companies) not taking into account that the stimulus applied in the tests will help the patient to progress.

Results of evaluation

With regard to the results obtained, we emphasize that, in more than half of the patients, we were unable to continue the program because they were transferred. It would be important for the MSP to be part of good practices in other institutions so that there was continuity of care. We trust that, at least, the family members we advised had some follow-up, as the results show that patients who had their family actively involved progressed more points in average on the GCS. Therefore we recommend encouraging family involvement whenever possible. As stated in the RCP Guidelines⁵, this involvement is a generally welcome opportunity for family and friends to play a positive role during visits.

The results of our MSP show that more than half of the patients evolved in their state of conscious (54.55%), in the GS (63.64%) and in the LCFS (54.55%). If the program had continued, how many more patients would evolve? In the study by Doman et al.,¹⁹, of the 200 patients with brain damage and GS equal to or less than 6, who underwent a MSP, 91% emerged from a coma. However, Lombardi et al.,²⁰, when reviewing the literature on sensory stimulation in patients with brain injuries who were in a coma or VS, found that the few controlled studies that exist are of relatively low quality, and therefore not the effectiveness of these programs can be clearly demonstrated.

Also Cabral et al.,⁶, in a literature review, concluded that there is still no scientific proof of the effectiveness of MSP.

Observations during MSP application

It was with the olfactory stimulus that we observed more reactions, especially in patients in coma and VS. We know from neurophysiology that smell has direct access to the brain without going through the thalamus as in other directions²¹.

Freiherr²² states that olfactory information not passing through the thalamus, on its way to the neocortex, may be the reason for the multiplicity of unconscious processes involved in olfactory perception. The olfactory system is strongly connected with the limbic system, resulting in responses to odors with a strong emotional tone and a robust relationship with memory processes. These characteristics of the olfactory system form the basis of the perception of smell that makes it unique, among other sensory perceptions.

The fact that olfactory and gustatory reactions are evident even in patients in coma, goes against what Caldas²³ mentions, about smell and taste, “they seem to be felt with functions that are more disconnected from cognition and more adapted to the information of more primitive systems of nervous function”.