Welcome to the TBI-HELP Live Chat

Our Guest is: Dr. Angelo Canedo,  
     Vice President, Rehabilitation Medicine, 
     Jamaica Hospital Medical Center
Today's topic is: "Coma Stimulation: Techniques and Strategies"

[19:10:31] Mod: Good evening Carol and welcome. The Dr. that was here last week will participate at a later date. However, we have with us tonight an expert on traumatic brain injury. Your question regarding regenerating brain cells and spinal cord cells will be answered shortly.
[19:11:14] Dr._Canedo: Yes Carol there is some research being conducted on cell regeneration.
[19:11:46] Dr._Canedo: This research is based on the idea that young cells often have the potential to grow new connections and tracts
[19:12:02] Dr._Canedo: It is a challenging effort in cyto-architecture
[19:12:08] Mod: What does unisensory mean??
[19:13:25] Dr._Canedo: Unisensory means that AS BEST AS POSSIBLE YOU USE ONE SENSORY MODALITY FOR EXAMPLE SIGHT OR SMELL AND TRY TO FOCUS ON THE RESPONSE TO THE ONE STIMULUS YOU PRESENT
[19:13:27] Mod: Rail: what kind of response is elicited?
[19:14:18] Dr._Canedo: The response is difficult to evaluate
[19:15:02] Dr._Canedo: It is often a grimace or a withdrawal from something noxious or something unexpected.
[19:15:40] Dr._Canedo: It is in the observation that you need the most clinical acumen and some of it is experience
[19:15:44] Mod: Rail: On Carol's point - is this where placenta tissue is being tried as a source of 'young cells'?
[19:17:20] Dr._Canedo: There are efforts to use placenta tissue and efforts to look at the use of neonate cells in vitro to try and grow cells in a controlled laboratory environment.
[19:17:44] Dr._Canedo: The results are promising but there a a host of newfound difficulties with each trial
[19:18:22] Dr._Canedo: There is hope for the future as animal implants have been promising and cells have grown in implanted animals
[19:18:31] Mod: Carol: How far along is the research...
[19:19:28] Dr._Canedo: The research is in its infancy but early results are impressive albeit difficult to control and not yet ready for human trials
[19:20:02] Mod: Rail asks.. At what coma level is best served by stimulation?
[19:20:34] Dr._Canedo: All clients in a subaroused or minimally responsive state are candidates for an aggressive stimulation program
[19:21:15] Dr._Canedo: First they must be evaluated for a potential response using observational and hard wire data such as galvanic skin response
[19:22:05] Dr._Canedo: Then there is a period of clinical trials and close observation followed by evaluation and then an adjustment of the program to account for the new level of responding
[19:22:33] Dr._Canedo: It is a stepwise program of trial, evaluation, monitoring , adjustment and retrial
[19:23:37] Mod: Dan, welcome, his question is pertaining to skin response.
[19:23:44] Dr._Canedo: Yes, the skin produces both electrochemical and secretory reactions to stimuli
[19:24:53] Dr._Canedo: In research conducted by a close colleague of mine here at the Brady Institute he found that of six or so physiological measures the GSR [Galvanic Skin Response] was the most telling in terms of client response.
[19:25:20] Dr._Canedo: He will be talking about this research when he presents on that work in a few weeks
[19:25:51] Mod: mike: in your opinion do individuals in a coma hear what is going on?
[19:26:24] Dr._Canedo: The research is mixed on true client awareness.
[19:27:10] Dr._Canedo: However there are many clients who I have worked with that tell me of their recollections during coma
[19:27:22] Dr._Canedo: Some I have been able to verify and it shows that we certainly do not fully know how to monitor this response
[19:28:28] Dr._Canedo: It is certainly possible from a minimally responsive state to have awareness but not be able to demonstrate it to an observer herein is where physiological monitoring holds great promise
[19:28:30] Mod: maria12560@juno: Can I be in a coma if my eyes are open?
[19:29:20] Dr._Canedo: Yes you can be in coma with your eyes open. However most clinicians define that as a post coma or vegetative state
[19:29:42] Dr._Canedo: That is a term that I dislike but it is common clinical parlance
[19:30:06] Dr._Canedo: I refer to this state as the minimal responsive or protracted coma state
[19:30:30] Dr._Canedo: The difference is in how responsive a person is to presented stimuli
[19:30:35] Mod: I just saw the question about hearing and coma do you mean that someone can remember what they heard...if so how can I get them to communicate back to me?
[19:31:22] Dr._Canedo: Knowing that they heard you is the problem given today's science
[19:31:57] Dr._Canedo: While there are indications of the brain processing sound that can be measured IE through ABR

[19:32:38] Dr._Canedo: Knowing whether they processed that auditory engram and then decoded it is where we are stymied
[19:33:29] Dr._Canedo: I therefore prefer to assume that a client might hear me and respond accordingly as I have had clients who could recall what their mother said to them when she came to visit from out of state etc.
[19:33:58] Dr._Canedo: The presumption of processing is not totally scientifically founded but is not disproven either
[19:33:59] Mod: mike: what are the legal rights of a woman carrying a baby in a coma?
[19:35:39] Dr._Canedo: I would hesitate to address this as I am not an attorney nor an expert on legal rights. However, I know that we will be having future speakers who are attorneys and experts in TBI law, I would suggest that you hold that question for their thoughts
[19:36:28] Mod: \ mrsbeck: is it better to talk to a comma patient about things they know about or new information?
[19:37:07] Dr._Canedo: The best approach is to talk to them about things that would interest you and them
[19:37:53] Dr._Canedo: The flow of conversation and the introduction of topics that interest them and you allows for the free flow of conversation as we all know it
[19:38:23] Dr._Canedo: What we know about the brain is that arousal and awareness are impacted by feelings and interests
[19:39:17] Dr._Canedo: By highlighting issues that are emotionally and personally interesting you maximize the limbic and emotive responses of the individual and increase the response potential

[19:40:03] Mod: mrsbeck: does the age of the coma victim effect how they respond to stimuloii?
[19:41:03] Dr._Canedo: Age plays a role in recovery as we are pretty sure that younger people are more malleable and have better recovery rates and greater potential for plasticity
[19:41:19] Mod: <just sitting here>
[19:41:32] Dr._Canedo: However it is not a direct correlate to how well someone in coma responds at any given point in time
[19:42:50] Dr._Canedo: The best predictor of awareness is generally the degree of responsiveness shown by that sole person and The response quality i.e. generalized vs localized or consistent vs inconsistent, etc
[19:42:52] Mod: Moose: Hi Moose here...can you tell me about some of the newest coma stim techniques available?
[19:44:47] Dr._Canedo: The latest interventions are often electrical conductance of controlled skin stimulation or controlled auditory frequencies and intensities using sound regulators
[19:46:10] Dr._Canedo: There is also greater use of multi-sensory vs only uni-sensory stimuli under the argument that most of the times we use our entire sensory system and integrate the sensory experience across sensors and intensities
[19:46:47] Mod: PattiSue: Can that be said in simple terms
[19:46:59] Dr._Canedo: Sorry I got carried away with the jargon
[19:47:59] Dr._Canedo: Basically we are now turning towards the presentation of more natural stimuli and more natural situations rather than using amore laboratory model that dissects any stimuli into parts
[19:48:46] Mod: Moose: Moose comin at yah...how are the auditory frequencies used if we are unsure if the person can process the stimulation how would you ascertain?
[19:49:00] Dr._Canedo: My dear colleague moose is running me through the hurdles in the interest of getting me to talk in plain English
[19:49:15] Dr._Canedo: The truth is that we are not sure about a lot of this
[19:49:44] Dr._Canedo: We are using theory to guide practice to a large extent and this does not always hold up
[19:50:35] Dr._Canedo: Unfortunately we are not yet able to monitor many of these responses even in part so the idea of monitoring them is a complex response is beyond us
[19:51:22] Dr._Canedo: Computer models help but in the end we are still taking baby steps in largely uncharted waters and we are using basic principles of clinical practice
[19:52:04] Mod: maria12560@juno: Can a man be sexually aroused while in a coma?
[19:52:43] Dr._Canedo: Arousal needs to be discriminated apart from the perspective of psychological or psychogenic vs pure sensory and physiological
[19:53:57] Dr._Canedo: Clients may have reflexive erections due to tactile stimulation or visceral responses. It is unlikely that a person in a minimally responsive state could have volitional erections
[19:55:16] Dr._Canedo: However as I noted before we are not totally sure of how much any one given individual is aware of despite our inability to observe same and therefore we cannot say for sure
[19:56:09] Mod: Moose: Once again its Moose time...got to Say this was good stuff...my antlers are off to you...
[19:57:08] Dr._Canedo: Thank you for the compliment this is an exciting topic and one of the remaining frontiers in TBI recovery
[19:57:47] Dr._Canedo: Our knowledge is growing everyday and we are learning how to develop interventions that increase the potential for response
[19:58:22] Dr._Canedo: For one we are learning that the quality oif a response may be as much of a variable as the actual response
[19:59:23] Dr._Canedo: By knowing how consistent the response is to a repeated stimuli we can get a sense of whether we are getting a steady state or a variable state and we can correlate this to time and degree of arousal etc
[19:59:27] Mod: Dr. Canedo a question was asked sometime ago, and I'm not sure we answered it. Is aromatherapy good to be used with people in a coma?
[20:00:28] Dr._Canedo: Aromatherapy is certainly a sensory stimulus and can be of value in a coma stimulation program
[20:01:03] Dr._Canedo: Once again to be able to monitor its effects we must apply controls in intensity , type and frequency
[20:02:26] Dr._Canedo: In some setting it is known as olfactory stimulation which is a fancy word for the presenting of aromas and the observation of their impact on responses on both observed and physiological measures
[20:02:28] Mod: Dr. Canedo we want to thank you for a very interesting evening and we look forward to having you as a guest speaker in the near future. To all our viewers, thank you for coming to our chat room and for future guest speakers please check our calendar on our web site. Thank you and good night to all.
[20:03:37] Dr._Canedo: Thank you for the opportunity to share what I hope are some of the things that will further our ability to care for comatose individuals in the future