Francesca Buonocunto

Technology-based intervention options for post-coma persons with minimally conscious state and pervasive motor disabilities

Background: Intervention strategies, based on learning principles and assistive technology, were assessed with four post-coma persons with minimally conscious state and pervasive motor disabilities. Method: The first study taught a man to access environmental stimulation through a response-microswitch combination and another man to access environmental stimulation and request social contact through responses combined with a microswitch or a Voice Output Communication Aid (VOCA). The second study taught a man to access two forms of environmental stimulation via two response-microswitch combinations and another man to request two forms of contact via two response-VOCA combinations. Results: Data showed that all participants had significant increases in response levels (independent of whether the responses were combined with microswitch or VOCA devices) during the intervention phases of the studies. Conclusion: Intervention strategies based on learning principles and technology may be largely helpful for persons with minimally conscious state and pervasive motor disabilities.

Two persons with severe post-coma motor impairment and minimally conscious state use assistive technology to access stimulus events and social contact

Arranging and testing environmental/behavioral (i.e., non-medical) intervention programs for persons with severe post-coma motor impairment and minimally conscious state can be very challenging, and the experimental evidence available in the area is fairly limited [1–5]. Two environmental/behavioral intervention strategies, which might be used as a guide in this process, rely on general sensory stimulation and learning principles combined with assistive technology, respectively [1,2,5–9]. The first strategy rests on the notion that sensory stimulation may enhance recovery from brain injury, may reduce the risk of sensory deprivation that is highly likely in persons who have limited contact with the outside world, and may promote alertness while counteracting low arousal and withdrawal phenomena [5,10,11]. Sensory stimulation may occur through daily sessions involving the presentation of orientation cues and commands, general noises, familiar voices, radio and television clips, lights, vibrotactile inputs, or odors [5,12,13]. The second strategy relies on the notion that a learning setup and assistive technology might be used to help the person acquire/consolidate simple responses instrumental to access specific (preferred) environmental stimulation and positive human contact [14–17]. The expectation is to build an association between the responses and their positive effects (i.e., to enable the person to acquire some awareness of the link between his or her behavior and the immediate environment and thus enhance his or her level of consciousness and functional engagement) [15]. The latter strategy may be considered quite adequate in enriching the stimulation input, promoting an active role for the person, increasing his or her level of performance, and possibly developing his or her control of behavior and environmental events and ultimately his communication. The same strategy can also be easily adjusted (extended) over time to suit the person’s progress and emphasize his or her improving social image [15,18]. In spite of these positive aspects, the use of this strategy has been minimal and the need for new application efforts is clear [19,20]. This study was one such effort. It assessed a program based on the use of learning principles and assistive technology with two persons with a diagnosis of severe post-coma motor impairment and minimally conscious state. The program was intended to help the persons bring about brief periods of environmental stimulation through a microswitch and request contact with the caregiver through a voice output communication aid (VOCA). The microswitch and the VOCA were introduced in sequence and eventually were made simultaneously available so that the participants could decide (choose) about their use.

Microswitch- and VOCA-Assisted Programs for Two Post-Coma Persons with Minimally Conscious State and Pervasive Motor Disabilities

Intervention programs, based on learning principles and assistive technology, were assessed in two studies with two post-coma men with minimally conscious state and pervasive motor disabilities. Study I assessed a program that included (a) an optic microswitch, activated via double blinking, which allowed a man direct access to brief music intervals, and (b) a voice output communication aid (VOCA) with two channels, activated via different hand-closure movements, which allowed the man to call his mother and a research assistant who provided stimulation events. Study II assessed a program that included (a) a pressure microswitch, activated via head movements, which allowed a man direct access to video-clips and music, and (b) a VOCA device, activated via prolonged eyelid closure, which allowed the man to call the caregiver (i.e., a research assistant) who provided attention and sung to him. Each of the two participants had significant increases in both microswitch- and VOCA-related responses during the intervention phases of the studies. Moreover, purposeful choice seemed to occur between the two VOCA responses in Study I. Implications of the findings for improving the situation of post-coma persons with minimally conscious state and pervasive motor disabilities are discussed.

Technology-assisted messaging opportunities for two persons emerged from a minimally conscious state and showing extensive motor disabilities

Objective: To extend the assessment of a special messaging technology with two adults emerged from a minimally conscious state and showing extensive motor disabilities as well as limited or no oral/verbal skills. Method: The study involved a non-concurrent multiple baseline design across participants. Both participants started with baseline in which the technology was not available, and continued with intervention in which the technology was used. The technology involved a net-book computer provided with specific software, a global system for mobile communication (GSM) modem, microswitches, and pre-recorded lists of persons and messages. Results: Both participants learned to send out and receive (listen to) messages independently during the intervention. They sent out a mean of three or three and a half messages and received a mean of one and a half messages per 20-minute session. Conclusions: Special messaging technology may help post-coma persons with multiple disabilities engage in basic communication with distant partners.

Access to environmental stimulation via eyelid responses for persons with acquired brain injury and multiple disabilities: a new microswitch arrangement.

This study assessed a new microswitch arrangement for eyelid responses using an optic sensor placed above the cheekbone and a small sticker on the persons eyelid. This new arrangement, which was designed to avoid interference of the microswitch with the persons visual functioning, was tested on three adults with acquired brain injury and multiple (consciousness, communication, and motor) disabilities. The study was carried out according to a non-concurrent multiple baseline design across participants. Data showed the new microswitch arrangement was suitable for all three participants, who increased their responding during the intervention phase of the study when their responses allowed them to access preferred stimulation. Practical implications of the findings are discussed.

Technology-based programs to support forms of leisure engagement and communication for persons with multiple disabilities: Two single-case studies

Objective: To extend the assessment of technology-based programs for promoting stimulus choice and staff/caregiver calls or radio operation and text messaging. Method: In Study I, the program involved a portable computer, commercial software, and a microswitch to allow a man with motor impairment and moderate intellectual disability to choose among preferred stimuli (e.g., songs and film clips) and persons to call. In Study II, the programs involved (a) a radio device and an electronic control unit or (b) a net-book computer and a global system for mobile communication. A woman with blindness and moderate intellectual disability used a microswitch to operate the radio or send and listen to text messages. Results: The participants succeeded in using the technology-aided programs through simple microswitch activations involving partial hand closure (Study I) or hand pressure (Study II). Conclusion: Technology-based programs can provide persons with multiple disabilities relevant leisure and communication opportunities.

Evaluation of technology-assisted learning setups for undertaking assessment and providing intervention to persons with a diagnosis of vegetative state

Objective: To evaluate the viability of technology-assisted learning setups for undertaking assessment and providing intervention to persons in vegetative state. Method: Study I investigated whether three persons with a diagnosis of vegetative state could associate eye blinking or hand closure responses with contingent, positive stimulation, thus increasing their frequencies (showing signs of learning). Study II extended the learning process (introducing a new response and new stimuli) for one of the participants of Study I. Results: Two of the participants of Study I succeeded in increasing their responses, indicating signs of learning. Study II showed that the participant (one of the two succeeding in Study I) acquired a new response to access new stimuli and could alternate this response with the one acquired in Study I. Conclusion: Learning might represent a basic level of knowledge and consciousness. Detecting signs of learning might help modify a previous diagnosis of vegetative state and support intervention/rehabilitation efforts.

Special text messaging communication systems for persons with multiple disabilities

Objective: To expand recently-developed text messaging systems with new technology-based solutions so as to allow persons with multiple disabilities to write messages. Method: Two case studies were conducted. In Study I, the new technology-based solution involved vocal scanning of the alphabet letters to allow letter selection/writing and was assessed with a woman with blindness and extensive motor disability. In Study II, the new technology-based solution involved a touch-screen superimposed on letter symbols arranged alphabetically and was assessed with a man with acquired brain injury, motor disability and lack of speech. Each study involved an ABAB design. Results: Participants learned to write their messages, to send them out and to listen to incoming messages during intervention sessions of nearly 30 and 20 minutes, respectively. Conclusion: Text messaging systems can be developed that allow participants with multiple disabilities to write messages.

A learning assessment procedure to re-evaluate three persons with a diagnosis of post-coma vegetative state and pervasive motor impairment

Primary objective: Detecting signs of learning in persons with a diagnosis of post-coma vegetative state and profound motor disabilities could modify their diagnostic label and provide new hopes. In this study, three adults with such a diagnosis were exposed to learning assessment to search for those signs. Procedure and design: The assessment procedure relied on participants’ eye-blinking responses and microswitch-based technology. The technology consisted of an electronically regulated optic microswitch mounted on an eyeglasses’ frame that the participants wore during the study and an electronic control system connected to stimulus sources. Each participant followed an ABABCB design, in which A represented baseline periods, B intervention periods with stimuli contingent on the responses and C a control condition with stimuli presented non-contingently. Main outcomes and results: The level of responding during the B phases was significantly higher than the levels observed during the A phases as well as the C phase for all participants (i.e. indicating clear signs of learning by them). Conclusions: These findings may have important implications for (a) changing the participants’ diagnostic label and offering them new programme opportunities and (b) including learning assessment within the evaluation package used for persons with post-coma profound multiple disabilities.

Post-coma persons emerged from a minimally conscious state and showing multiple disabilities learn to manage a radio-listening activity

This study assessed microswitch-based technology to enable three post-coma adults, who had emerged from a minimally conscious state but presented motor and communication disabilities, to operate a radio device. The material involved a modified radio device, a microprocessor-based electronic control unit, a personal microswitch, and an amplified MP3 player. The study was carried out according to a non-concurrent multiple baseline design across participants. During the intervention, all three participants learned to operate the radio device, changing stations and tuning on some of them longer amounts of time than on others (i.e., suggesting preferences among the topics covered by those stations). They also ended a number of sessions before the maximum length of time allowed for them had elapsed. The practical (rehabilitation) implications of the findings were discussed.