Our Guest is: Dr. Lou Zimmer,  of United Cerebral Palsy

[19:00:47] Mod: Good Evening and welcome to our live moderated professional chat. Tonight we are honored to have as our guest speaker Dr. Louis Zimmer, former Director of Neuropsychology at Baylor Institute for Rehabilitation in Dallas, Texas
[19:01:22] Mod: Currently Dr. Zimmer is Supervising Neuropsychologist at United Cerebral Palsy in Nassau County
[19:02:05] Lou: Good evening.
[19:03:03] Mod: Dr. Zimmer can you please explain what is a coma?
[19:03:36] Lou: A coma is a state of reduced responsiveness
[19:03:57] Lou: The person in a coma is unable to awaken.
[19:04:51] Mod: So this is different from a deep sleep? Can you explain more?
[19:05:49] Lou: A person in a deep sleep may not be responding very much but there is always a loud noise or some other stimulus that can wake them up.
[19:06:04] Lou: This is not so in coma.
[19:07:04] Mod: Can stimulation from family members help the person in a coma regain their normal life. Example wake up?
[19:08:24] Lou: The family members can definitely assist the person in a coma to wake up. In some cases it is the stimulation that the family provides that may actually be the factor that brings the person out.
[19:10:25] Mod: Should the stimulation be something that the person is used to hearing? Or should it be something totally different?
[19:11:27] Lou: It could be either. Often the stimulus that makes a difference and elicits a response is something familiar. However, a totally new type of stimulation may get their attention better. It is a matter of trying different things.
[19:12:20] Mod: When you say the stimulation can be the factor that brings the person out of the coma are you referring to the term responding?
[19:13:27] Lou: There are many ways to look at the term respond. Some responses are very basic reflexes. At the other extreme are behaviors such as complex conversations.
[19:14:31] Mod: Other than sounds, what other stimulation can help bring someone out of a coma?
[19:15:20] Lou: Any type of stimulation can be used as part of a coma stimulation program. Lights or objects that the person can see are another type. Familiar odors or different kinds of touch are also used.
[19:19:58] Mod: [From Rail] Lou - What is the most common monitor method for coma patients?
[19:20:08] Lou: the most common and most frequently used coma scale is the Glasgow Coma Scale or GCS for short.
[19:21:20] Mod: Melanie asks: I've been reading about vestibular therapy and its aim to provide the patient with an input to the balance mechanism of the brain in an attempt to awaken the patient and to stimulate those parts of the brain concerned with balance. Is this good?
[19:21:41] Lou: That's a great question! Vestibular therapy involves moving the person around passively. This provides touch as well as vestibular or positions sensation. and is a good way to stimulate the person.
[19:23:40] Mod: Dr. Zimmer we have a question from Rail that refers to the Coma Scales. Do the Coma Scales require an evaluation by someone with experience. Isn't there some technical monitoring that is being used?
[19:23:42] Lou: Just about any way of measuring coma requires some experience. There are some ways to try to measure the level of coma using physiological measures such as EEG or heart rate but they do not seem to be much better than behavioral methods.
[19:25:58] Mod: Hi, This is Amanda here with Melanie. A patient may be able to see, hear, smell etc. but may have no way of responding to the stimulus verbally or with movement. What type of testing can be done to elicit whether there is an attempt at response?
[19:26:09] Lou: If there a motor impairments that may prevent the person from responding. In the extreme cases this is called Locked in Syndrome. In this case the only responses that the person may have only eye movements. There are some ways to try and measure heart rate changes or skin conductance responses but these require special equipment and experience.
[19:28:40] Mod: rail comments: Go on about the vestibular stimulation - is there any way to monitor the subtle effects of this activity to see what brain activity may be correlated with the stimulation?
[19:29:57] Lou: The treatment staff can use either behavioral methods such as one of the coma scales or one of the physiological measures. Either of these is sensitive if used carefully and repeatedly - day after day to observe subtle changes.
[19:30:56] Mod: Another from Rail: Disney did a remake of the Helen Keller story last night - is there some parallel to coma recovery in the profound changes in brain processing that may lead to some functional recovery?
[19:32:00] Lou: Helen Keller was never in a coma so the idea using training techniques for the blind or deaf would not likely work here.
[19:33:25] Mod: Carol: I came on later but how can you tell by monitoring a coma patient if they are getting some stimulation or hearing what is happening?
[19:34:10] Lou: Hello Carol. In order to see what is going on during the stimulation the therapist must be a very good observer of behavior and look for subtle and often inconsistent changes in behavior.
[19:35:09] Mod: Carol: When you monitor a coma patient, what types of signs do you look for that would indicate some brain activity?
[19:35:22] Lou: Often these response, such as a head turn or eye opening are brief and then disappear. This can be confusing but seems to be a normal part of the recovery process. The signs you look for are sometimes very hard to distinguish. The response may be a slight movement of an arm or leg or a flutter of the eye lids. As the person recovers the responses become more obvious and involve the person reaching for objects or avoiding intense stimuli.
[19:38:37] Mod: rail comments: Lou - I think you missed my point -Given that Trauma is often a part of coma, isn't there some retraining, or actually new brain function established in cased where there has been anoxia damage or direct trauma? And, aren't some of the same tactics applicable ( as with Helen) in these cases post coma??
[19:39:28] Lou: Hi Ron. Sorry I missed your point. At first after the onset of anoxia or some other injury the nerve cells are doing their best to recover what function they can. Stimulation may help to facilitate this process. As time goes on, Many months, then the process of nerve cells re-growing and reconnecting begins. Stimulation may also facilitate this process
[19:40:43] Mod: Melanie: You look for controlled movement as opposed to reflex?
[19:42:47] Lou: At first you do look for reflexes. Those may be the first responses that there is some recovery. However, reflexes alone do not indicate that the person is out of a come. The controlled responses such as attempt to reach and touch someone or nod their head yes/no are the responses we look for to indicate that a person is out of their coma
[19:43:44] Mod: Dave: Can someone exhibit only marginal signs of movement and then after some time begin to "wake up" from coma?
[19:44:42] Lou: A person can exhibit those marginal response for quite some time and then begin to show responses indicating recovery. Usually recovery is more consistent and graded but if there is one thing we know it is that every patient is different.
[19:45:57] Mod: PattiSue here again. So the brain can reorganize and relearn as cells re-grow and heal?
[19:47:18] Lou: The idea of reorganization as the brain heals is being accepted more and more over the years. For a long time it was felt that once a brain cell dies, that's it and no more changes in any of the remaining cells can happen. Researchers found that cells could reorganize in some animals and now in humans under some conditions. The bigger question is whether new connections actually work.
[19:48:20] Mod: Dave: How does this happen...is it part of the recovery process or does it have to do with the function of the brain and the extend of the trauma?
[19:49:38] Lou: It is likely part of the normal recovery process. However, the more extensive the damage the more difficult it would be for reorganization to occur.
[19:49:50] Lou: Did I answer the question?
[19:49:50] Mod: PattiSue... Awakening is nothing like in the movies is it?
[19:51:28] Lou: You are very right. Awakening after a real coma is a gradual process which occurs over many days, weeks or sometimes months. Responses come and go but there is a gradual trend of improvement. Occasionally there is a report of someone who just wakes up one day but that is extremely rare.
[19:52:35] Mod: Rail: So why isn't some technology being used to give insights into the unseen in monitoring these patients?
[19:54:44] Lou: There has been a number of attempts to use EEG equipment and a type of special electrical response called an evoked potential to measure brain activity during coma. The equipment is specialized but more importantly the information does not yet anyway tell us anymore than observing behaviors. There might be some benefit in using new technologies such as MRI but the benefits have not been proven.
[19:55:29] Mod: Dave: Saw an article in the NY TIMES re: about stem cells and regenerating cells...can this work on the TBI patient and how far are we from seeing this as an offered course of treatment?
[19:57:41] Lou: The NY Times article was very intriguing. Some day the use of stem cells to help the nervous system recover from injury would be wonderful. Right now there are many biological hurdles as well as ethical ones that need to be answered. Cell transplants have been
[19:58:32] Lou: found to be beneficial in treating Parkinson's but it doesn't always work for some reason and the results are often fleeting when it does work
[19:58:36] Mod: Amanda has an interesting question for you. Why don't most people who come out of coma remember the incident that caused the coma?
[19:59:43] Lou: This inability to recall what happened around the time of the coma is related to the way our memory works. In order for information about what happens to us the memories must pass from a short to a long term memory. The injury that causes the coma disrupts this process so that these events never get stored in long term memory
[20:01:15] Mod: I want to thank Dr. Lou Zimmer for being with us tonight and for the very interesting chat session. I hope that he will join us again in the future. Thank you for participating in our session and Good Night.
[20:01:46] Lou: Thanks for all the great questions