Coma

INITIAL SUMMARY

Coma, due to brain injury, is not an isolated phenomenon, but is instead an integral part of the unbroken continuum that extends from death and profound coma at one end of the spectrum to very mild brain injury and normality at the other.

The authors have been led to this conclusion during more than forty years of treatment of more than fifteen thousand brain-injured children and adults in a clinical as well as in a hospital setting. Patients have ranged from those in a profound coma or moderate coma, through profoundly brain-injured, severely brain-injured, moderately brain-injured, to mildly brain-injured.

The authors utilized a program aimed at the injured central nervous system rather than at the resultant peripheral symptoms, which relied heavily on visual, auditory, tactile, gustatory, and olfactory stimulation. This stimulation was given with greatly increased frequency, intensity, and duration, sometimes in multiples of ten or greater. By combining this stimulation with a program to improve respiratory function, the authors have succeeded in moving patients through this continuum, often to normality

THE TREATMENT OF COMA

Historical Background

The comatose state has been widely regarded as being unyielding to therapeutic intervention and for the most part the treatment of the comatose individual has consisted of supportive care while awaiting spontaneous recovery or, more likely, a persisting vegetative state. As the outcome of our work of over forty years with brain-injured individuals, we have developed concepts of neurological function that are applicable to all degrees of severity of injury, including coma.

Traditionally brain injury has been regarded as a static and irrevocable fact.

The traditional present-day treatment of brain-injured children was derived largely from the closing decades of the nineteenth century and embellished in the first half of the twentieth century.

Consequently the concepts, classifications, diagnoses, philosophies, methods, techniques, and objectives of present-day treatment are entirely symptomatic in origin and are aimed at the periphery of the brain-injured child, wherein lie his symptoms, rather than at the brain wherein lies the cause of the coma, paralysis, speechlessness, blindness, deafness, apparent mental retardation and other problems that beset the brain-injured child.

Such an approach has led inevitably to objectives that are palliative rather than curative with resultant lifetime institutionalization of profoundly brain-injured children and extremely limited human goals for moderately or mildly brain-injured children.

Millions of children worldwide are so disposed.

The cost of this traditional approach in both human and economic terms staggers the imagination.

The literature stands virtually silent on the actual results achieved by these methods of treatment that are predicated upon the naive assumption that centrally-directed, non-surgical treatment of the brain itself is not possible and that, therefore, it is possible only to deal with the physical, psychological, social, and emotional consequences of brain injury. In brief, the symptoms.

These conventional methods in virtually universal use are entirely unvalidated by controlled studies.

CONCEPT

This paper reports on a centrally directed, non-surgical treatment of coma and its sequel in brain-injured patients.

"It must then be considered as a basic principle that when a lesion exists within the confines of the brain, treatment, to be successful, must be directed to the brain wherein lies the cause rather than to that portion of the periphery where the symptoms are reflected. Whether the symptoms exist as an almost undetectable subtlety in human communication or in an overwhelming paralysis, this principle must not be violated by those who seek success with the brain-injured patient."¹

The team of child brain developmentalists who compose the staff of The Institutes for the Achievement of Human Potential, after treating some fifteen thousand children from six continents have come to the following conclusion:

The fact that the brain responds to stimulation and grows by use has been well known to neurophysiologists for half a century. They have also known that the opposite is true.²

Tragically, the ultimate in child abuse, severe or profound sensory deprivation inflicted by criminal or psychotic parents, provides us with the unwelcome but useful opportunity to observe what happens when children receive the precise opposite of a program of child brain development.

Infrequently, but all too often, someone accidentally discovers a child whose very existence was kept secret by insane parents who had kept the child prisoner by chaining him to a bedpost in a darkened attic or by confining him to the darkness and silence of a locked closet.

Such children, depending on the duration and the depth of sensory deprivation and the age at which the child suffered this epitome of child abuse, suffer consequences ranging intellectually from severe retardation to absolute idiocy, and ranging physically from paralysis to profound arrest of growth.

Recently in America, neighbors discovered such a child. The child was not only speechless but, despite being nine years of age, was reported to be physically the size of a two and a half year old.

What other means are there to examine what is actually happening in the brain? Both of these points have been proven over and over again by animal experimentation that gives sensory deprivation to one group of laboratory animals while providing sensory enrichment to their matched littermates.

In a paper by Bennet, Diamond, Krech, and Rozenzweig, University of California, Berkeley, presented to the World Organization for Human Potential in Philadelphia on May 31, 1969, David Krech sums up the findings of his group both succinctly and literately, by stating:

"After a lifetime spent giving environmental enrichment to one group of rats, and environmental deprivation to their matched littermates, it is clear that the rats raised in environmental enrichment have large, highly developed, highly intelligent brains, while their littermate brothers and sisters, raised in environmental deprivation, have small, stupid, underdeveloped brains."

"It would be scientifically unjustifiable to assume that, because this is true in rats, that it is also true in people . . ."

Having given science its just due, Krech then shows great wisdom by adding: ". . . and it would be socially criminal to assume that it were not true in people."

Boris Klosovskii, as chief of neurophysiology and pediatric neurosurgery at the Academy of Medical Sciences of the USSR, Moscow, did a classical experiment in visual stimulation more than a half century ago. Newborn puppies and kittens, raised on a slowly revolving platform and sacrificed between the tenth and twentieth day of life had 22.8% to 35% more brain growth in vestibular areas of the brain than did their littermates who did not see a moving world.

Neuroanatomist Marion Diamond reported to the World Organization for Human Potential in Philadelphia on May 9, 1986, that she could actually measure the amount of brain growth that took place in laboratory animals after four hours of stimulation.

Brain-growth and development are a dynamic and ever-changing process in brain-injured children as well as in unhurt children. This is a process that can be reversed, as it is in coma. This is a process that can be stopped, as it is in profound brain injury. This is a process that can be slowed, as it is by moderate brain injury, but most significantly it is a process that can be speeded.

Brain injury acts a barrier between the brain and the visual, auditory, tactile, gustatory, and olfactory stimulation offered by the outside world. The more severe the injury the more complete the barrier; the more diffuse the injury, the more functions are intercepted.

Coma due to brain injury does not exist as an isolated phenomenon. It is, instead, an integral part of an unbroken physical, intellectual, and social continuum that extends from death at one end of the spectrum, through profound and moderate coma, through profound, moderate, severe, and mild brain injury, and to normality at the other end of the spectrum. We know this continuum to be useful in understanding both comatose states and the pathway to normality that follows. By the age of 84 months we have found that the average child in a modern culture is able to perform the six functions that characterize human beings in a totally useful way. We therefore use a neurological age of six years to identify neurological maturity at any chronological age (see chart).

MATERIALS

The authors have for more than forty years dealt very directly with more than fifteen thousand brain-injured children, as well as hundreds of adults. These children have ranged in age from newborns to twenty years of age. They have ranged in severity from profound coma to mildly brain-injured in physical, intellectual and social terms (see chart). The distribution of these children as to severity of brain injury is as follows:

• Profoundly brain-injured 37%
• Severely brain-injured 44%
• Moderately brain-injured 15%
• Mildly brain-injured 4%

No percentage of patients in coma is shown since all of the above patients, including the adults, were seen in The Children's Clinic rather than in a hospital setting. Hundreds of these patients had been in coma at the time of the parents' first application for admission to the program of The Institutes. Most of these patients had been in coma for weeks or months, although some had been in coma for periods up to more than two years.

Although we had taught the patients' families how to carry out the Coma Arousal Program³ in a one-week course at The Institutes in Philadelphia, we had not actually seen the majority of the patients themselves, and therefore did not maintain charts on them until the Coma Arousal Program had succeeded and they could be brought to The Institutes to be evaluated and programmed.

The program used to arouse our patients from coma is exactly the same program used to treat the profoundly brain-injured after he has been aroused from coma, as described in this article. As the patient increases in neurological age, the program utilizes additional concepts, methods, and techniques to achieve higher function.

For the purpose of this study, brain injury is defined as a lesion that lies in the brain, whether of a traumatic or nontraumatic nature. This includes brain injury that occurred prior to, during, or subsequent to birth. Diagnosis of brain injury was made after extensive historical investigation and extensive functional neurological examination.

Laboratory findings were obtained where indicated and include neurosurgical intervention, examination of cerebrospinal fluid, CAT's, MRI's, PET's, and EEG's, as well as laboratory, blood, and biochemical tests, and others where required.

Progress is measured on a Developmental Profile, which measures the chronology of normal growth in visual competence, auditory competence, tactile competence, mobility competence, language competence, and manual competence at seven significant stages between birth and six years of age.

This profile then delivers a neurological age that, when compared with chronological age, gives a precise measurement of the degree of injury, as well as the brain-level or levels involved. A patient in profound coma delivers a neurological age of zero on the Developmental Profile.

The Developmental Profile is then used to measure the results of treatment to normality, or to the precise degree of success or failure in each of the six areas of cortical function that characterize neurological normality in man.⁴

This Profile is highly reliable and has face validity. It has been used to measure neurological age in tens of thousands of individuals in many nations and on at least five continents. Neurosurgeons and pediatricians in Japan, China, Malaysia, Brazil, and Italy now use The Institutes Developmental Profile when referring children to The Institutes.

METHOD

The earliest methods of coma arousal were designed by the child brain development team at The Institutes more than thirty years ago and have continued to be improved and sophisticated over the years.

During that time The Institutes have utilized coma arousal procedures on children from every continent and taught families to use these procedures at home.

Because the results of such a procedure are highly dramatic, this aspect of the work of The Institutes has gained much international attention.

In his classic text for parents,⁵ Dr. Edward LeWinn, for whom the Edward LeWinn Institute for Research is now named, changed ever so slightly the classical definition of coma. Rather than "Coma is a state of unconsciousness from which the patient cannot be aroused," he stated, "Coma is a state of unconsciousness from which the patient has not yet been aroused."

The change is slight but highly significant. Obviously brain injury creates a barrier between the brain and the environment that, in the case of a patient in coma, cannot be penetrated by visual, auditory, tactile, olfactory, or gustatory stimuli at normal levels of frequency, intensity, or duration.

To penetrate the barrier, it is necessary to increase the frequency, intensity, and duration of stimuli by multiples of five, ten, and even more. The multiple used is the smallest that will accomplish the results.

When a patient has been in a coma for a period of months or years, the patient has been traditionally provided with life-sustaining medical and nursing care in a room kept as quiet and free from stimulating environmental impingement as possible. His bed is in a private room with curtains drawn, silence enforced, and as far from noisy areas as possible. He is handled only when necessary.

Exactly the opposite is required if such a patient is to have his chance for recovery. All studies in auditory, visual, and tactile deprivation indicate that a well human being placed in such a sterile environment would degenerate neurologically. Such degeneration will have its effect in physical, intellectual, and social terms.

In contrast to this, the principles of child brain development demand that such a child should be provided with the greatest, rather than the least, impingement from his environment.

As a result of the foregoing, a child in coma, immediately following the subsidence of cerebral edema, should be placed in a room that is the center of stimulation in an auditory, visual, tactile, gustatory, and olfactory sense. Such a child is functionally blind, deaf, insensate, and without gustatory or olfactory appreciation.

At The Institutes for the Achievement of Human Potential, such a child's bedside table contained a flashlight, two blocks of wood, a tuning fork, pins, brushes, sniff jars containing various strong-smelling but unharmful substances, jars containing strong-tasting but harmless substances, such as English horseradish, Italian garlic, Japanese mustard, and a variety of other stimulus-producing tools.

In addition to regularly and frequently scheduled periods during which the above procedures were utilized, each professional person who passed the child's room was directed to stop long enough to open the child's eyes and shine the flashlight into them, to strike the blocks of wood together sharply against each other near his ear, to pinch his skin, to stick him gently with the pin, to place the tuning fork on various joints, to brush his skin briskly with various textured brushes, to pass the various aromas contained in the bottles under his nose briefly, and to place on his tongue very small amounts of strong-tasting foods, insufficient in quantity for him to choke or aspirate.

When stimulation such as these is introduced, one frequently sees a patient respond by seeing, hearing, feeling, tasting, and smelling in a matter of days or a very few weeks, even though he may have been in a comatose state for months or even years.

In addition, the patient is given a heavy respiratory program, which is often as much as twelve hours out of each day.

The respiratory program consists of positive pressure respiratory patterning, masking, and breathing a mixture of oxygen and carbon dioxide for very brief sessions throughout the day.

RESULTS

A. Function:

The results achieved in each of four years (1984, 1985, 1986, and 1987) were reported in each of those years by The Institutes. Approximately 450 children were seen in each of those years, with the following results:

Crawling: Of 423 children who were unable to move at the beginning of the year, 69 (16.30%) crawled for the first time, thus moving from a botanical state to an amphibian state. (They ranged in age from 9 months to 20 years.)

Creeping: Of 239 children who could crawl but not creep at the beginning of the year, 72 (30.10%) crept for the first time, thus improving from an amphibian state to a mammalian state. (They ranged in age from 12 months to 16 years.)

Walking: Of 234 children who could creep but not walk at the beginning of the year, 64 (27.4%) learned to walk during the year, thus progressing from a mammalian state of mobility to an anthropoidal state. They walked without help or aids of any kind. (They ranged in age from 20 months to 26 years.)

Running: Of 339 children who could walk but not run at the beginning of the year, 65 (19.20%) could run in complete cross-pattern, thus moving from the anthropoid state to the exclusive state of human beings. (They ranged in age from 32 months to 12 years.)

Seeing: Of 134 children who were functionally blind at the beginning of the year, 24 (17.90%) could see and read at the end of the year. (They ranged in age from 15 months to 24 years.)

Reading: Of 472 children who could not read at the beginning of the year, 336 (71.20%) learned to read during the year. (They ranged up to 24 years in age.)

Writing: Of 343 children who could not write at the beginning of the year, 68 (19.80%) learned to write during the year. (They ranged in age from 45 months to 20 years.)

Hearing: Of 6 children who were functionally deaf at the beginning of the year, 3 (50%) gained the ability to hear during the year. (They ranged in age from 50 months to 8 years.)

At the end of the year, 124 children could walk, run, talk, write, and read, but were neurologically less than perfect (had a strabismus, had occasional seizures, etc.)

B. Physical Growth:

Since 1961, the staff of The Institutes has taken extremely careful anthropological measurements of each child's head, chest, height, and weight on his or her initial visit and on each successive visit. Measurements have been made on over 7,000 children.

About 13,500 measurements are performed on about 450 different children per year.

Let's consider a population of children on the program of The Institutes.

Brain-injured children are not only small, but so strikingly small that this fact can be used as a diagnostic aid. For example, of a total population of 987 children who were consecutively admitted to the program, 785 (79.50%) at admission had a head circumference less than the 50th percentile. Another 485 (49.10%) of these children had a head circumference less than the 10th percentile.

These children ranged in age from 24 months through 19 years, with a mean age of 64 months. The average length of time on program was 32.4 months.

Of the 785 children who had heads below the 50th percentile in circumference at the onset of the program, 403 (51.30%) increased their rate of head growth during the program beyond that of their chronological peers by 156.9%.

The fact that more than half of the brain-injured children whose heads had grown at slower rates than had those of their chronological peers prior to the program of child brain development does not in itself constitute prima facie evidence that brain growth has been markedly increased, but it is nonetheless highly suggestive that such is the case.

C. Seizures and Convulsions:

Exactly 76.60% of convulsive children who were having seizures when admitted to The Institutes' program and who were removed from anticonvulsants had either no subsequent seizures (41.70%) or had a decrease in seizures (34.90%) following the graduated detoxification program of The Institutes. This result we consider to be a strong indication, if not conclusive proof, of brain development in a physical, chemical, or organizational sense, possibly of all three.

Brain development leads to physical, intellectual, and social growth throughout the spectrum of human ability from profound coma to normality and even to superiority.

SUMMARY

In the opinion of the authors, coma is much more easily understood and more successfully treated when viewed as an integral part of a very real physical, intellectual, and social continuum.

by Glenn Doman

ENDNOTES

1 Glenn, Doman, Lecture delivered to staff of the Institute of Physical Medicine & Rehabilitation (New York, 1953).

2 Edward B. LeWinn, M.D. and Mihai Dimancescu, M.D., "Environmental Deprivation and Enrichment in Coma," The Lancet (July 15, 1978).

3 Edward B. LeWinn, M.D., "The Coma Arousal Team," Royal Society of Health Journal (February, 1980).

4 Edward B. LeWinn, M.D., "The Measurement of Neurological Development," International Journal of Neuropsychiatry, Vol. III, No. 2 (1967).

5 Edward B. LeWinn, M.D., Coma Arousal, The Family as a Team (New York, 1985).