States of Consciousness

When I was taking my undergraduate degree in Human Kinetics, I had the opportunity to take a class called Human Growth and Development. Here, I learned about how a human grows, stages of development, and essential functions of infant life such as primitive reflexes. I had never correlated how these could ever relate to adults (as I knew I did not want to work with paediatrics), but after considering neurological injuries I had realised that many adults revert back to having primitive reflexes (such as a Babinski Reflex, which signals spinal damage), or communicating in such a way that infants may.
I had physiotherapy placement on a ward for Traumatic Brain Injuries, for a short-term, intensive rehabilitation program. Here, we would work with patients who were acutely unwell (such as stroke patients, those who have overdosed, and some road traffic accident victims to list a few). The majority of the patients were in disorders of consciousness. This means they were either in vegetative, locked in, or minimally conscious state, with a few emerging.
A Vegetative state is defined as “when a person is awake but showing no signs of consciousness (NHS, 2015). This means that they have sleep-wake cycles, may open their eyes, and have some reflexes such as a startle reflex, but they cannot track with their eyes, or appropriately respond to any stimuli, nor do they experience any emotion.
A Minimally Conscious State is defined as when they show “clear but minimal or inconsistent awareness” (NHS, 2015). This means that they are able to periodically communicate or respond to questions such as giving a thumbs up or blinking but generally have difficulty doing this consistently. Sometimes, achieving a minimally conscious state after emerging from a coma is a stage to recovery, but in other cases, patients are bound to this state for the rest of their lives.
A Locked in State is when a patient is “conscious and aware, but completely paralysed and unable to speak”(NHS, 2015). In this state, they can usually communicate using their eyes. In order to do so, now there is an abundance of eye-tracking technology that can allow patients in this state to type with their eyes, or navigate on a screen to be able to communicate. Additionally, they can consistently blink to yes/no questions, and amazingly, an alphabet board was created where they can communicate with others by following the board and blinking. It’s difficult to explain, so below is a youtube video link to explain it.
Physiotherapists are able to help those who had emerged from these states to do stretches, exercises, and use equipment such as standing hoists and tilt tables to try to restore some general function for these patients. For those who were less able, we conducted daily passive stretches to avoid muscular contractures progressing and inhibiting any movement, and to allow for increased comfort for the patient (Latchem, Kitzinger, and Kitzinger, 2016.) This will allow for ease of carer burden to make tasks such as washing the patient easier. We also serial cast them to stretch out their limbs, used botox treatments, and used the tilt tables with them as well to allow them upright interaction with the world (Wheatley-Smith et al., 2013).
Interestingly, I had a patient who came into our intensive rehabilitation centre in a Vegetative State (and had been in that state for the past 4 months, so did not have a very good prognosis from that stage forward). Soon after his arrival, however, he began to emerge from the Vegetative State. While not being able to speak due to a cognitive impairment secondary to a stroke he had suffered, we were able to restore some functional mobility from the gentleman to the point where we were able to help him to walk again with a partial weight-bearing treadmill, and later to minimal support. Though he still needed some assistive devices such as an Ankle Foot Orthoses (AFO) to counterbalance his foot-drop, he was able to achieve enough restoration to move him to a higher functioning traumatic brain injury ward.
Needless to say, I think I found the niche I would love to specialise in Physiotherapy in once I graduate and do some rotations. I found nothing to be as interesting asTraumaticc Brain Injuries up to this point.
References
Disorders of consciousness. (15, September 23). Retrieved February 16, 2017, from
Latchem, J., Kitzinger, J. and Kitzinger, C., 2016. Physiotherapy for vegetative and minimally conscious state patients: family perceptions and experiences. Disability and rehabilitation, 38(1), pp.22-29.
Wheatley-Smith, L., McGuinness, S., Colin Wilson, F., Scott, G., McCann, J. and Caldwell, S., 2013. Intensive physiotherapy for vegetative and minimally conscious state patients: a retrospective audit and analysis of therapy intervention. Disability and rehabilitation, 35(12), pp.1006-1014.

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