Gianfranco Megna

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.

High and low frequency transcutaneous electrical nerve stimulation inhibits nociceptive responses induced by CO2 laser stimulation in humans.

The aim of the study was to evaluate the effects of transcutaneous electric nerve stimulation (TENS) on CO(2) laser evoked potentials (LEPs) in 16 normal subjects. The volar side of the forearm was stimulated by 10 Hz TENS in eight subjects and by 100 Hz TENS in the remainder; the skin of the forearm was stimulated by CO(2) laser and the LEPs were recorded in basal conditions and soon after and 15 min after TENS. Both low and high frequency TENS significantly reduced the subjective rating of heat stimuli and the LEPs amplitude, although high frequency TENS appeared more efficacious. TENS seemed to exert a mild inhibition of the perception and processing of pain induced by laser Adelta fibres activation; the implications of these effects in the clinical employment of TENS remain to be clarified.

Post-Coma Persons with Extensive Multiple Disabilities Use Microswitch Technology to Access Selected Stimulus Events or Operate a Radio Device

The present two studies extended research evidence on the use of microswitch technology by post-coma persons with multiple disabilities. Specifically, Study I examined whether three adults with a diagnosis of minimally conscious state and multiple disabilities could use microswitches as tools to access brief, selected stimulus events. Study II assessed whether an adult, who had emerged from a minimally conscious state but was affected by multiple disabilities, could manage the use of a radio device via a microswitch-aided program. Results showed that the participants of Study I had a significant increase of microswitch responding during the intervention phases. The participant of Study II learned to change radio stations and seemed to spend different amounts of session time on the different stations available (suggesting preferences among the programs characterizing them). The importance of microswitch technology for assisting post-coma persons with multiple disabilities to positively engage with their environment was discussed.

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.

Electronic Baropodometry in Patients Affected by Ocular Torticollis

Aims: To evaluate, by means of electronic baropodometry (EB), the postural findings in patients affected by ocular torticollis. Methods: Posturographic analysis (length of the sway path, sway area, and mean velocity) was made in 54 patients with IV palsy, Duane Syndrome, or rectus superior palsy (group A) and compared with a control group of 45 healthy subjects (group B). The test was performed with both eyes open, then both closed, then with the affected eye open, and finally with the healthy eye open. Results: With both eyes open or closed, the length of the sway path, the sway area, and mean velocity were significantly increased in group A compared with group B (P<0.0001). When the open eye was the one with the muscular paresis, the length of the sway path was significantly increased as compared with the healthy eye (P<0.0001), and the sway area was increased too (P<0.029). No statistical differences were observed mean velocity according to which eye was open (P=NS). Conclusions: EB is a useful instrument for studying secondary postural anomalies in patients affected by OT.

Combined antimuscarinics for treatment of neurogenic overactive bladder.

Antimuscarinic drugs are the first line pharmacotherapy for overactive bladder, but they are not always effective to achieve complete continence. Nevertheless in some patients urodynamic investigations reveal insufficient effects with continuing incontinence events even with dose optimization. The aims of this study is to evaluate the effect of association of Oxybutynin chloride, Trospium chloride and Solifenacin succinate administered orally for a minimum of 12 weeks in subjects with suprasacral spinal cord injury with urge-incontinence, urodynamic–proven neurogenic detrusor overactivity dysfunction and detrusor-external sphincter dyssynergia to improve level of continence, reduce the risks of urologic complications and enhance QOL. This study was a randomized, double blind, controlled, balanced-parallel-groups investigation of orally administed Oxybutynin in addition to Trospium chloride in the first group and Oxybutynin in addition to Solifenacin in the other group. A total of 12 patients with neurogenic detrusor overactivity and clean intermittent catheterization were allocated into two treatment groups: 5 mg tablet of Oxibutinin and 20 mg tablet of Trospium Chloride were administed respectively 3 times a day and 4 times a day in the first group (Group A). 5 mg tablet of Oxibutinin and 10 mg tablet of Solifenacin were administed respective 3 times a day and once daily in the second group (Group B). In both group of patients we found a significant decrease in incontinence episodes, with an improvement of bladder compliance, bladder capacity and volume voided. Side effects were higher in patients of group B, but in general well tolerated. In conclusion a combined antimuscarinic treatment might be a right option for patients affected by neurogenic bladder refractory to previous antimuscarinic monotherapy, and might slow down or delay other more invasive treatments.

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.

BOTULINUM TOXIN TYPE A IN THE TREATMENT OF SIALORRHEA IN PARKINSON'S DISEASE

protein (CRP) and erythrocyte sedimentation rate (ESR) were 261 mg/L and 137 mm/h, respectively. Blood and urine cultures were negative. X-rays of the feet showed osteoarthritic changes. Chest x-ray showed no pulmonary pathology. Over the following 48 hours, the pain and swelling progressed to involve the metatarsophalyngeal joints, wrists, and elbows bilaterally; swinging fevers and rigors persisted. On-call staff started her on ceftriaxone for suspected sepsis. The patient subsequently developed a blanching nonpruritic maculopapular rash involving the arms, legs, and trunk. A vasculitic, myeloma, and arthrogenic virus screen and computed tomography (CT) imaging of the abdomen and pelvis were normal. Complement levels, C3 (0.75 g/L) and C4 (0.08 g/L) were low, and lymphopenia persisted. Given the cluster of symmetrical, inflammatory arthritis; rash; lymphopenia; low complement levels; extremely high ESR (4100 mm/h), and her history of miscarriages, we queried acute systemic vasculitis and arranged a rheumatology consultation. An aspirate of the first metatarsophalyngeal joint revealed monosodium urate crystals and neutrophils consistent with gout. A skin biopsy showed small vessel lymphocytic vasculitis with eosinophilic tissue invasion typical of an allergic reaction. The cephalosporin was discontinued, and colchicine was commenced. Serum urate level was 0.41 mmol/L. Within 2 days, all symptoms and signs had resolved, and she could mobilize independently. Eight weeks later, her ESR had fallen to 46 mm/h and CRP to 4 mg/L. Gouty arthritis in elderly people presents differently from that in the non-geriatric population and differs between men and women. Although younger adults typically have monoarticular symptoms, up to half of geriatric patients develop polyarticular disease, although this presentation seems more prevalent in men. Consequently, gout can often be misdiagnosed as rheumatoid arthritis, lupus erythematosus or osteoarthritis. Because estrogen appears to have a uricosuric effect, older women are more prone to attacks than younger women, partly because of higher urate levels; 50% to 60% of people aged 60 and older and almost all of those aged 80 and older with gout are female. Gout is also commonly associated with osteoarthritis. The use of diuretic agents, especially thiazides, is seen in up to 60% of geriatric patients with gout but more frequently in women and mostly in the presence of impaired renal function. Gout is commonly seen in obese patients with metabolic syndrome, in whom high levels of endogenous insulin act on renal tubules to cause urate retention. There is also an association between gout and cardiovascular morbidity, perhaps mediated by obesity, insulin resistance, and hypertension. This elderly obese female patient also had these comorbidities, as well as osteoarthritis, and was on diuretic therapy. There were several atypical features in this case. The involvement of multiple joints sequentially was unusual but has been reported elsewhere. The high fever suggested underlying sepsis but can be seen in more than 40% of cases of polyarticular gout. Administration of an antibiotic clouded the diagnosis by inducing an allergic rash. Extreme elevation of ESR is rarely encountered in acute gout, and levels greater than 130 mm/h have not been reported. Baseline ESR is higher in elderly people, but only a few serious disorders typically result in levels greater than 100 mm/h at any age. The classic presentation of gouty arthritis is acute monoarticular involvement in a middle-aged man. The recognition of atypical manifestations, as demonstrated in this elderly patient, is important. Although this patient had some of the common presenting features and risk factors for gout in this age group, she also had many atypical findings, which made the diagnosis difficult, a dilemma previously noted. One should consider gout in the geriatric patient with acute polyarthritis even if there is swinging pyrexia and features of possible sepsis. Acute gout should also be added to the list of possible causes of extreme elevation of ESR.