Dr. Edwin Cooper from North Carolina has been involved in some interesting and promising research indeed. He has developed a treatment which seems to be able to increase alertness and levels of consciousness after severe brain injury resulting in coma.

Dr. Cooper found us after reading our post on using Electrical Stimulation to Increase Awareness and we, of course, immediately asked him to share more about this exciting technique.

He graciously provided an article which I have “blogified” below. The original article he wrote for us is attached in case you are as excited as we are and want to read more. Any “errors in translation”, oversimplifications, or inappropriate informalities are my own. I’ve also included some links to more stories about this technique at the end of the article –

But let’s let Dr. Cooper tell you about his research….

RIGHT MEDIAN NERVE STIMULATION FOR TREATMENT OF COMA STATES

Edwin Cooper, MD & Bryan Cooper, MD North Carolina, USA © March 2008
A Gateway to Consciousness

Turn your right hand so you can see your palm. At your wrist, right there in the middle is the general location of your right median nerve. Gaze in wonder there for just a second….

Why? Because the median nerve is a portal — a gateway — to the brain. Electrically stimulating it can stimulate and help arouse the central nervous system for persons with reduced levels of consciousness after brain injury.

How? By increasing blood flow to the brain and raising levels of dopamine, a neurotransmitter associated with information flow between brain areas. It also seems to increase certain kinds of brainwave activity that are associated with learning and the connecting of information between brain areas.

For Whom? Nerve stimulation is not really all that new. It has been used in the U.S. for acute coma after traumatic brain injury for 15 years and neurosurgeons in Japan have been using electrical stimulation even longer — implanting electrodes on the spinal cord at the neck level for individuals experiencing long-term levels of minimal awareness.

But the use of right median nerve electrical stimulation (whew — let’s just use RMNS) for patients in coma for longer periods(subacute and chronic) is relatively new. Using electrical stimulation to treat anoxic brain injury (i.e., damage from lack of oxygen) as well as traumatic brain injury is evolving and it’s still not clear how useful RMNS will be for those individuals.

From the Wrist to the Brain?

We’re going to take a look at some of the stories of people with whom RMNS has been used, but let’s pause for a minute and see why this technique may be able to have some of the amazing results it has achieved. (If you absolutely can’t wait, go read this article from Wired magazine about a young woman named Candice and then come back….)

Back in the late 1980s, in a research project through Duke University in North Carolina, individuals living with quadriplegia were able to trigger their paralyzed forearm and hand muscles to move through using voice-activated surface electrical stimulation. Imagine — they could use their voice to initiate an electrical pulse that produced movement in their arm and hand muscles.

But this technique didn’t only allow voluntary hand opening and closing — an unexpected result was that there was improvement in the strength of the muscles of the opposite, unstimulated, arm. The only way this can happen is by the electrical signal actually traveling through the brain – from one arm to the brain to the other arm.

Why is this so exciting? Because it means that we can try to impact dysfunctional brain areas “indirectly” through the peripheral nerves. We don’t necessarily need to directly influence the brain to make a difference in functioning. And this observation led to the development of RMNS as a technique for arousal from coma.

RMNS coma-stimulation projects were started at East Carolina University and the University of Virginia in the early 1990s. The goal was to try to speed awakening from coma and enhance involvement in active rehabilitation. The technique uses small electrical neuromuscular stimulators (like those you may have seen used in rehabilitation if you’ve ever had TENS used for pain reduction) connected to a plastic cuff to deliver electrical stimulation to the right median nerve. The stimulation is given eight hours a day for two to three weeks for persons in deep coma starting about one week post injury.

So far, observations in the U.S. and Japan of individuals in acute and long-term coma states, show progressive improvements after several weeks of electrical stimulation. These seem to follow a pattern of increased eye coordination followed by improvements in facial control, peripheral motor (arms and legs) movement, and speech.

The Earlier, the Better

In the 1990s, researchers at the University of Virginia and East Carolina University in North Carolina did a series of pilot studies. RMNS was used with about 36 people with severe closed head injury. Before considering the results, we need to know that when individuals have a Glasgow Coma Scale score of 4-5 and show a certain kind of physical position associated with severe brain injury (called “decerebrate” or “decorticate” posturing), few of them can be expected to make good recoveries.

With RMNS, the time for awakening from coma was typically twice as fast as in the non-stimulated group. And gradual recovery to a functional level was approximately twice as frequent as in the group who did not receive RMNS.

What Can We Really Expect?: Some Real Life Tales
Candice was an active and vivacious 16-year-old high school student with a love of dancing.

In 1994, she was involved in a motor vehicle crash, resulting in a severe closed head injury. She had a number of injuries to her head and brain: including a skull fracture, leaking cerebrospinal fluid from her brain, multiple “bruises” within her brain, and a fracture of the bones on the left side of her face. She was breathing only with assistance. She had the “decerebrate posturing” and a GCS score of 4. She was not expected to recover in any meaningful. functional, way.

Candice was briefly started with RMNS stimulation, but the fluid pressures in her brain continued to rise. With her extremely poor prognosis, she was expected to die. The breathing tube was removed, less than two weeks after her injury.

Unexpectedly, she was able to keep breathing on her own and her parents decided to re-start the RMNS. Within one week of restarting the electrical RMNS neuro-stimulation, she showed some semi-purposeful movements of her right arm and leg and scored 7 on the GCS. After a total of two weeks of stimulation, she was out of coma.

One month after the injury, Candice followed simple commands. At two months, she could walk with assistance and could read aloud. Two years later, Candice talked and walked well. She resumed dancing and driving and graduated from college. Now over a dozen years after awakening from coma, she works full time in Recreation Therapy at a retirement home.

You can hear and read more about Candice in the links at the end of this article.

JP is a good example of the advantage of starting RMNS in the first month of coma.

JP was a 16-year-old girl in Southern California whose car was T-boned (side impact) by a truck in June 2002. At the scene she was having trouble breathing and was unresponsive, having a GCS of 3-4.

The CT scan showed bleeding deep in her brain and extensive “tearing” of tissues in her left fronto-temporal lobe and corpus callosum. Like Candice, she also had elevated pressure on her brain caused by the fluid inside and around it. JP remained in coma and was decerebrate/decorticate at four weeks post injury. She received median nerve electrical stimulation (six hours per day on both sides instead of just the right) starting 5 weeks after her injury. She stayed in the ICU for her entire two-month hospitalization.

Two weeks after the electrical stimulation was started, although she was still left hemiplegic (unable to move her left side), she was now able to follow commands. She was transferred to a rehabilitation unit 8 weeks after she was injured.

JP was discharged from a residential facility to home to the care of her family in early March of 2003, eight and a half months post brain injury. She continued to receive outpatient therapies.

In the spring of 2003 (less than one year after her injury), she graduated from high school on schedule with her class. In the fall of 2003, she started college by taking three courses and made B grades (ed: translation for Canadians – that means generally 80-90%). She continues to do well years later.

What Can We Learn from This Approach?

Regardless of what causes the coma or reduced level of awareness, RMNS electrical stimulation may be able to help “kick-start” the central nervous system functions. Even after using RMNS, we still need the rehabilitation efforts and family input to retrain the abilities of the injured brain and motivate the person.

And we can’t predict the final neurological outcome.

But the partnership of neurosurgical and medical treatments performed quickly after the severe brain injury with RMNS of the comatose person in the early weeks post injury should give better results than traditional methods of watchful waiting.

____________________________________________________

My comments:
Dr. Cooper and his son have given us a very low-key overview of the potential of RMNS. It is amazing that a young woman could have an injury as severe as this, be in an ICU for 2 months, and yet less than a year later graduate from high school with her class and do well in university-level classes, without skipping a beat.

What don’t we know about RMNS? The question that probably is the Big One for most of our readers: Is it useful for helping individuals injured months or years previously?

Dr. Cooper shared with me that the ideal time for RMNS is at the end of the 1st or 2nd week of coma. But even months later it can help, although he’s really not sure about its use with individuals after a year or more of living at a minimally responsive level of recovery.

For more:
Dr. Cooper’s original article:
Wired magazine’s article about Candice, Dr. Cooper, and the use of RMNS: Back from the Dead

Or go to Dr. Cooper’s website to watch two videos: one about Candice originally presented on the Discovery Channel in Canada and on the National Geographic channel in the U.S.; the other is a demonstration of the use of RMNS with several individuals. Makes for very exciting viewing…..and well worth your time!