Beruflich Dokumente
Kultur Dokumente
RESEARCH PAPER
1
IRCCS ‘Eugenio Medea’, Bosisio Parini (LC), Italy, 2AIAMC, Milano, Italy, and 3Florida State University, Tallahassee,
FL, USA
Abstract
Purpose. To present a cognitive-behavioural stimulation (CBS) protocol designed to help severely damaged patients in the
early post-acute stage by describing the underlying methodology and assessing its efficacy compared to traditional
For personal use only.
rehabilitation methods. This protocol combines multisensory stimulation and cognitive-behavioural techniques to elicit and
intensify the occurrence of adaptive responses and reduce maladaptive behavioural patterns.
Methods. A control group and an experimental group – both evaluated with the Levels of Cognitive Functioning
Assessment Scale (LOCFAS) – were compared at the beginning of the rehabilitation programme and at the end of it. The
control group consisting of patients assessed and treated before receiving the CBS protocol was enrolled in a traditional
rehabilitation programme (only physical therapy and speech therapy). Besides the traditional therapy, the experimental group
also received the CBS protocol.
Results. Patients on the CBS protocol show a greater improvement and are therefore more responsive than the control
group after the 16-week remediation programme. The mean LOCFAS improvement of the experimental group is more
marked during the first month of rehabilitation and is associated to the entry LOCFAS level, while in the control group the
improvement on LOCFAS is considered to be ‘spontaneous’ and is associated to the aetiology of the brain damage.
Conclusions. Our results show a better initial outcome for patients receiving the CBS protocol.
Correspondence: Mariarosaria Liscio, PhD, Acquired Brain Injury Unit, IRCCS ‘Eugenio Medea’ Associazione La Nostra Famiglia, 23842 Bosisio Parini
(LC), Italy. Tel: þ39 31877111. Fax: þ39 31877499. E-mail: mariarosaria.liscio@bp.lnf.it
ISSN 0963-8288 print/ISSN 1464-5165 online ª 2008 Informa UK Ltd.
DOI: 10.1080/09638280701257023
276 M. Liscio et al.
introduced only later when patients become coop- reported in the literature [1,5,25 – 28]. In contrast to
erative and conscious and show more appropriate this, there are few studies on rehabilitation in the
behaviour patterns. Some protocols can also include early post-acute stage and, more specifically, on the
multisensory stimulation and music therapy to application of cognitive-behavioural techniques im-
improve the patient’s responsiveness and facilitate mediately after patients awaken from coma
recovery. Multisensory stimulation is based on the [1,4,5,25 – 30].
assumption that multimodal stimulation increases
arousal and produces behavioural changes by stimu-
Objectives
lating the activation level of the brain reticular
system. It thus facilitates a shift to wakefulness, The goals of the present study included:
prolongs vigilance, enhances generalized attention
and stimulates the patient [7 – 17]. Music therapy is (1) To compare the cognitive-behavioural func-
based on the assumption that the patient stores some tioning level and responsiveness in two
memories that can be recalled by providing music different groups of patients suffering severe
cues [18 – 20]. brain damage, at entry and at the end of
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to have measures assessing the patients’ cognitive (3) To compare and differentiate recovery by the
level. Hence, the need for assessment procedures same assessment method in these two groups
that are strictly related to neurobehavioural re- of patients by focusing on the effects that
sponses and allow to establish the patient’s cognitive CBS has on the patients’ responsiveness.
functioning. To this end, the Levels of Cognitive (4) To identify the clinical and demographic
Functioning Assessment Scale (LOCFAS) was variables associated to recovery.
chosen [21 – 24].
The CBS protocol uses specific multimodal Our assumption was that the experimental group’s
stimulation to elicit adaptive responses from the recovery and improvement on the LOCFAS may be
patient, combined with cognitive-behavioural tech- qualitatively different from those of the control group
niques to reinforce such adaptive responses and and that multisensory stimulation combined with
eliminate or contain possibly maladaptive responses behavioural techniques could increase the rate of
that may manifest during recovery and interfere with recovery and responsiveness.
it. The goal is to stimulate and reinforce the patient’s We therefore wanted to test the hypothesis that, as
responsiveness by optimizing his/her resources and the CBS provides gradual, structured and guided
skills and turning them into means of communica- learning, it could help the experimental group to re-
tion and interaction with the environment. This organize and re-build their behavioural repertoire
would allow the patient to reach the maximum more easily and rapidly than the control group.
possible level of functional recovery compatibly with In our opinion, as the CBS provides gradual,
his/her disabilities and limitations due to the severity structured and guided learning, it can help the
of the insult [3]. Treatment goals – namely the experimental group to re-organize and re-build their
behavioural responses to be elicited – and the behavioural repertoire more easily and rapidly than
cognitive-behavioural procedures applied to pursue the control group.
these goals vary according to the LOCFAS level the
patient falls into.
The CBS protocol is, therefore, an attempt at Methods
applying cognitive-behavioural techniques in the
Inclusion criteria
early days of recovery to leverage the effects of early
rehabilitation and ensure the efficacy of cognitive- This study involved patients with profound brain
behavioural therapy in behavioural medicine and in damage and altered states of consciousness (coma,
the management of such complex neurological vegetative state, and minimal responsiveness) re-
pathologies at later stages of recovery, as already ferred to our Institute for clinical assessment and
CBS protocol for severely brain-damaged patients 277
control group (n ¼ 32) of patients previously referred levels correspond to five levels of progressive
to our Centre who only received physical therapy and cognitive recovery: the patient’s cognitive level is
speech therapy. the one affecting the majority of responses (see
The inclusion criteria included: (1) age between 0 Table I) [32].
and 18 years at the time of insult, (2) a GCS 8 at The quantitative analysis measures the frequency,
the time of injury, (3) time between insult and intensity and duration of responses or behaviours
assessment ranging between 0 and 12 months, and that are manifested spontaneously by the patient,
(4) LOCFAS level between I and IV. while the functional analysis looks at the relationship
The exclusion criteria included a positive history between the individual’s spontaneous behaviour and
of previous brain damage (congenital or acquired), some factors.
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pre-existing acute or chronic serious illness and During the initial assessment, when planning
psychological-behavioural disorders. Patients with a rehabilitation, detailed clinical data and information
LOCFAS level higher than 4 were excluded since about the patient’s behaviour and pre-traumatic
in our Centre they receive other rehabilitation features are collected. This can help in drawing a
therapies besides physical therapy and speech ther- general picture of the patient so as to identify the
apy. This was done to exclude possible biases as factors that may be used as stimuli/reinforcers or
these patients are included in different cognitive- aversive factors during rehabilitation.
behavioural rehabilitation programmes other than Both the behavioural responses to be elicited and
the CBS. the stimuli and techniques used to reinforce elicited
All the patients (or their parents) gave their written responses are measured against the results of this
informed consent to participate in the study. The comprehensive assessment.
study had been approved by our institution’s Ethics The assessment is repeated every week by the same
Committee. psychologist to monitor and quantify any improve-
The two groups were limited in number because of ment in the patient’s cognitive and behavioural
the strict inclusion and exclusion criteria that were picture, thus allowing for regular reviews of rehabi-
applied, but they are nonetheless appropriate for an litation efficacy and its objectives (see Figure 1).
exploratory study.
CBS methodology
Data collection
As stated, the CBS is an attempt at applying
For each patient the following data were collected: cognitive-behavioural techniques [33,34] since the
sex, age at insult and clinical data including early days of recovery to reinforce the patient’s
aetiology, GCS score (Glasgow Coma Scale), coma adaptive responses – either spontaneous or elicited
length, stage of recovery, previous neurosurgery, by multisensory stimulation – and re-build his/her
neurological exam, tracheotomy, artificial feeding behavioural repertoire. Figures 2, 3 and 4 show the
and epileptic seizures, LOCFAS level at entry and at main techniques used in the CBS protocol.
16 weeks, previous rehabilitation. The GCS is the The underlying principle is conditioning: the
most widely used scale to assess the consciousness patient associates a positive value to neutral beha-
level of a patient in coma state, and its reliability has vioural responses (unconditioned stimulus) – either
been widely validated. Trauma severity is classified spontaneous or elicited. Such positive value is a
according to three categories: severe (0 – 3), moder- positive reinforcement or the removal of an aversive
ate (4 – 8) and mild (9 – 13) [31]. stimulus in the case of negative reinforcement
278 M. Liscio et al.
(conditioning stimulus). Here the behavioural re- head, fingers, eyes, and producing vocalizations,
sponse is likely to be conditioned and to lead to a etc.) without communicative intent and meaning.
conditioned behaviour and an increase in condi- The aim is to have the patient associate the
tioned behaviour patterns as a whole. In a second behavioural response to the effects produced by the
stage, learning becomes more specific and is geared response on the surrounding environment.
to associating behavioural responses to a commu- These techniques can be divided into two large
nicative value and intent, as initially the patient categories: techniques positively reinforcing all the
produces behavioural responses (moving limbs, spontaneous adaptive responses – thus belonging to
CBS protocol for severely brain-damaged patients 279
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Figure 2. Techniques used in the CBS protocol to support spontaneous adaptive behaviours.
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the patient’s behavioural repertoire (Figure 2), and Objectives and techniques to move to LOCFAS Level III.
techniques favouring the acquisition and general- At this stage treatment is geared to consolidating
ization of new behavioural patterns (Figure 3) which previously learned information and stimulate eye
do not belong to the patient’s behavioural repertoire contact, explore and follow stimuli within the visual
and may allow for a greater functional adjustment to field, as well as elicit purposeful responses (move-
the environment. ments and vocalizations). These goals can also be
Rehabilitation by the CBS also includes beha- achieved by shaping, prompting, and fading. Purpo-
vioural techniques and procedures to reduce inap- seful responses include eye movements to follow
propriate behaviours (see Figure 4) that are applied stimuli within the patient’s visual field, grimaces in
according to the principle of the ‘less restrictive response to aversive or annoying stimuli, purposeful
treatment’ to pinpoint the procedures that can movements to remove aversive stimuli (for example,
effectively remove the inappropriate behaviour [33]. opposition to containment, attempts at removing the
Rehabilitation relies on clear objectives and nasogastric tube), and purposeful, yet irregular and
procedures. Once the patient has achieved all the delayed, movements to execute commands, vocaliza-
goals for a certain LOCFAS level, techniques and tions, high-pitched sounds or utterance of one or two
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procedures undergo another review to support words. Responses are defined ‘purposeful’ and
progression to the next level. ‘specific’ when they convey some meaning, a clear
intention to communicate or to reach a ‘goal’ (see
Objectives and techniques to move to LOCFAS Level II. Table III).
The first objective is to restore a steady vigilance
state, shifting from sleep to wake, reducing transition Objectives and techniques to move to LOCFAS Level IV.
times and prolonging the time the patient is awake. The goal is to help the patient explore the surround-
The focus of this stage is on non-specific and ing environment and make intentional use of
generalized responses to visual, acoustic, tactile, vocalizations and words. Techniques used at this
painful stimuli, and changes in posture. level include positive reinforcement (contingent and
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Table IV. CBS objectives and related techniques at Level III. between the two groups. The experimental group
LOCFAS Level III (Localized response)
and the control group can, thus, be compared for
sex, age, aetiology, recovery stage, and severity of
Objectives Techniques and procedures the clinical picture as measured by the GCS
. Consolidation of newly . Continuous contingent score, coma length in days and LOCFAS level at
learned information positive reinforcement entry. No significant differences were found for
. Fixation and following of . Negative reinforcement to clinical conditions and medical history (tracheotomy,
stimuli in the surrounding aversive stimuli artificial feeding and seizures), except for the motor
environment . Shaping
impairment as the experimental group shows a
. Intentional exploration . Chaining
of the surrounding . Modelling significantly greater impairment than the control
environment . Prompting group.
. Intentional use of . Fading Unlike the control group for whom we have only
vocalizations or words the entry and discharge assessment results (after 16
. Definition and intentional
weeks), the experimental group received regular
use of nonverbal
assessments (about every 4 weeks) allowing for a
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communication modalities
more precise description of their progress during
rehabilitation. The LOCFAS level at entry of the
experimental group was 1.86 (SD ¼ 0.78). At the
Table V. CBS objectives and related techniques at LOCFAS Level second assessment after 4 weeks of rehabilitation,
IV. the average LOCFAS level increased to 2.60 and
LOCFAS Level IV (Confused-agitated behaviour) continued to increase at the third assessment at 8
weeks (3.02, SD ¼ 0.83) and at the fourth assess-
Objectives Techniques and procedures
ment at 12 weeks (3.55, SD ¼ 1.17). The LOCFAS
. Consolidation of newly . Continuous contingent level at the end of the CBS was 3.98 (SD ¼ 1.39).
learned information positive reinforcement There is an average LOCFAS score increase by 0.74
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. Intention to communicate . Negative reinforcement at the end of the first month of rehabilitation, 0.42
and active search for to aversive
from the first to the second month, 0.53 from the
interaction with others stimuli
. Acquisition of orientation . Differential reinforcement second to the third month and 0.43 during the last 4
as to time and place of incompatible behaviours weeks of CBS.
. Increase in attention skills . Shaping At the entry assessment before CBS, 38.1% of the
. Extinction of inappropriate . Chaining patients were at LOCFAS Level I, while the
responses . Modelling
remaining 38.1% and 23.8% were at LOCFAS
. Intentional exploration of the . Prompting
surrounding environment . Fading Levels II and III, respectively (see Figure 5).
. Intentional use of . Cost of reply The mean global progress on LOCFAS during
vocalizations or words . Time-out the 16 weeks of rehabilitation is 2.09 (SD ¼ 0.61)
. Definition and intentional . Group psychostimulation for the experimental group and 0.56 (SD ¼ 0.90)
use of nonverbal . Reality test
for the control group. This difference is significant
communication modalities
(P ¼ 0.0001) (see Figure 6).
In contrast to the control group, the experimental
group’s progress on LOCFAS is correlated to age
Statistical analysis
(r ¼ 0.305, P ¼ 0.04) and the initial LOCFAS level
A chi-square test and an analysis of variance were (r ¼ 0.3112, P ¼ 0.045). Thus, the experimental
performed to compare and differentiate the patients’ group’s improvement is associated to age and higher
clinical profiles and cognitive-behavioural function- LOCFAS levels at entry: the older the patient, the
ing as well as the two groups’ improvement on the greater the improvement, and the higher the LOC-
LOCFAS. The analysis of variance and Pearson’s FAS level at entry, the greater the improvement after
correlation were also performed to investigate the rehabilitation.
association between the improvement on LOCFAS In contrast to the experimental group, the control
and clinical variables. Significant values were set at group’s progress on LOCFAS is associated to the
P 5 0.05. aetiology of the brain damage. Patients suffering
from an anoxic damage show a lower spontaneous
improvement (0.14) than post-traumatic patients
Results
(0.81) (r ¼ 3.59, P ¼ 0.04).
Table VI shows the clinical and demographic data of No significant associations were found in either
the two groups. groups between progress on LOCFAS and coma
As can be seen, no significant differences in length, seizures, tracheotomy, and artificial feeding.
clinical and demographic variables were found Similarly, no significant associations were found
282 M. Liscio et al.
Sex
Male 23 (54.8%) 23 (71.9%)
Female 19 (45.2%) 9 (28.1%) X2 0.13
Age 6.8 (SD: 6.8) 4.8 (SD: 3.6) ANOVA 0.06
Recovery stage
1st early post-acute stage 20 (47.6%) 10 (31.3%)
2nd early post-acute stage 12 (28.6%) 17 (53.1%) X2 0.10
Late post-acute stage 10 (23.8%) 5 (15.6%)
Etiology
Brain injury 18 (42.9%) 16 (50%)
Anoxia 13 (31%) 7 (21.9%) X2 0.67
Other (tumor, encephalitis, ischemia, etc.) 11 (26.1%) 9 (28.1%)
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between progress on LOCFAS – either spontaneous the older the patient, the more marked the improve-
or following remediation – and the degree of motor ment after CBS.
impairment or previous surgery or rehabilitation. The CBS thus seems to improve younger patients’
responsiveness less effectively. In fact, in our opinion
these findings can have a different explanation: the
Discussion
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