Communication in patients with disorders of consciousness – lessons learned From InteRDoCTor project

Jakub Komendziński, Emilia Mikołajewska, Dariusz Mikołajewski, Beata Augustyńska



Thanks to recent advances in health care an increased number of patients may recover from  severe brain injuries, but some of them are still assessed as non-responsive. Reliance on behavioural measures in communication with DoC patients seems be too prone to errors. There is need for solutions providing more objective attempts of bidirectional communication (intentional questions/commands and adequate related responses) in patients with DoC using significant processed by the patient stimuli and novel technologies (EEG-, fMRI-, BCI-based, etc.) based on recent scientific and clinical evidences. Such communication may be fulfilled even in the absence of behavior.

This article aims at assessment the extent to which current possibilities in the area of devices for extended communication has been exploited, including own experiences within InteRDoCTor project.


assessment; communication; brain injury; disorders of consciousness; assistive technology

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Komendziński T., Komendziński J., Mikołajewska E., Mikołajewski D. Ethics in communication with patients in the state of disorders of consciousness. Natural situation and the use of modern technologies. Postępy Psychiatrii i Neurologii 2016; 25(2):85-92.

Chabok SY, Kapourchali SR, Leili EK, Saberi A, Mohtasham-Amiri Z. Effective factors on linguistic disorder during acute phase following traumatic brain injury in adults. Neuropsychologia. 2012 Jun;50(7):1444-50.

Grauwmeijer E, Heijenbrok-Kal MH, Haitsma IK, Ribbers GM. A prospective study on employment outcome 3 years after moderate to severe traumatic brain injury. Arch Phys Med Rehabil. 2012;93(6):993-9.

Meguro K. Behavioral neurology in language and aphasia: from basic studies to clinical applications. Acta Med Indones. 2012;44(4):327-34.

Mikołajewska E. Neuroprostheses as an element of an eclectic approach to intervention in neurorehabilitation. In: Naik G, Guo I, editors. Emerging theory and practice in neuroprosthetics. IGI Global; 2014. p. 101–115.

Do CH. Coma in France today. Rev Infirm. 2015;(213):16-8.

van Erp WS, Lavrijsen JC, van de Laar FA, Vos PE, Laureys S, Koopmans RT. The vegetative state/unresponsive wakefulness syndrome: a systematic review of prevalence studies. Eur J Neurol. 2014;21(11):1361-8.

van Erp WS, Lavrijsen JC, Vos PE, Bor H, Laureys S, Koopmans RT. The vegetative state: prevalence, misdiagnosis, and treatment limitations. J Am Med Dir Assoc. 2015;16(1):85.e9-85.e14.

Pisa FE, Biasutti E, Drigo D, Barbone F. The prevalence of vegetative and minimally conscious states: a systematic review and methodological appraisal. J Head Trauma Rehabil. 2014;29(4):E23-30.

Kohnen RF, Lavrijsen JC, Bor JH, Koopmans RT. The prevalence and characteristics of patients with classic locked-in syndrome in Dutch nursing homes. J Neurol. 2013;260(6):1527-34.

Di Perri C, Stender J, Laureys S, Gosseries O. Functional neuroanatomy of disorders of consciousness. Epilepsy Behav. 2014;30:28-32.

Chabok SY, Kpourchali SR, Saberi A, Mohtasham-Amiri Z. Operative and nonoperative linguistic outcomes in brain injury patients. J Neurol Sci. 2012;317(1-2):130-6.

Puggina AC, Paes da Silva MJ, Schnakers C, Laureys S. Nursing care of patients with disorders of consciousness. J Neurosci Nurs. 2012;44(5):260-70.

Lee TM, Savage J, McKee H, Flament MP, D'Onofrio S, Eckert S. How do you know when your patient is "waking up": coma recovery assessment in a complex continuing care setting. Can J Neurosci Nurs. 2013;35(2):27-33.

Schnakers C, Chatelle C, Majerus S, Gosseries O, De Val M, Laureys S. Assessment and detection of pain in noncommunicative severely brain-injured patients. Expert Rev Neurother. 2010;10(11):1725-31.

Pistoia F, Sacco S, Sarà M, Carolei A. The perception of pain and its management in disorders of consciousness. Curr Pain Headache Rep. 2013;17(11):374.

Magee WL, Siegert RJ, Daveson BA, Lenton-Smith G, Taylor SM. Music therapy assessment tool for awareness in disorders of consciousness (MATADOC): standardisation of the principal subscale to assess awareness in patients with disorders of consciousness. Neuropsychol Rehabil. 2014;24(1):101-24.

O'Kelly J, Magee WL. The complementary role of music therapy in the detection of awareness in disorders of consciousness: an audit of concurrent SMART and MATADOC assessments. Neuropsychol Rehabil. 2013;23(2):287-98.

Magee WL, Siegert RJ, Taylor SM, Daveson BA, Lenton-Smith G. Music Therapy Assessment Tool for Awareness in Disorders of Consciousness (MATADOC): Reliability and Validity of a Measure to Assess Awareness in Patients with Disorders of Consciousness. J Music Ther. 2016;53(1):1-26.

Cortese MD, Riganello F, Arcuri F, Pugliese ME, Lucca LF, Dolce G, Sannita WG. Coma recovery scale-r: variability in the disorder of consciousness. BMC Neurol. 2015;15:186.

La Porta F, Caselli S, Ianes AB, Cameli O, Lino M, Piperno R, Sighinolfi A, Lombardi F, Tennant A. Can we scientifically and reliably measure the level of consciousness in vegetative and minimally conscious States? Rasch analysis of the coma recovery scale-revised. Arch Phys Med Rehabil. 2013;94(3):527-535.e1.

Sattin D, Giovannetti AM, Ciaraffa F, Covelli V, Bersano A, Nigri A, Ferraro S, Minati L, Rossi D, Duran D, Parati E, Leonardi M. Assessment of patients with disorder of consciousness: do different Coma Recovery Scale scoring correlate with different settings? J Neurol. 2014;261(12):2378-86.

Candelieri A, Cortese MD, Dolce G, Riganello F, Sannita WG. Visual pursuit: within-day variability in the severe disorder of consciousness. J Neurotrauma. 2011;28(10):2013-7.

Klingshirn H, Grill E, Bender A, Strobl R, Mittrach R, Braitmayer K, Müller M. Quality of evidence of rehabilitation interventions in long-term care for people with severe disorders of consciousness after brain injury: A systematic review. J Rehabil Med. 2015;47(7):577-85.

Mikołajewska E. Physiotherapy in patients undergoing mechanical ventilation. In: Maciejewski D., Wojnar-Gruszka K. (eds.) Mechanical ventilation – theory and practice. Alfa Medica Press, Bielsko-Biała 2016, p. 610-624.

Marti J-D, Ntoumenopoulos G, Torres A. Physiotherapy in mechanically ventilated patients: why and how. Clin Pulmon Med 2013;20(6):292-299.

Wu X, Zou Q, Hu J, et al. Intrinsic Functional Connectivity Patterns Predict Consciousness Level and Recovery Outcome in Acquired Brain Injury. J Neurosci. 2015;35(37):12932-46.

Rossini PM, Dal Forno G. Integrated technology for evaluation of brain function and neural plasticity. Phys Med Rehabil Clin N Am. 2004;15(1):263-306.

Mikołajewska E. Mikołajewski D. Clinical significance of computational brain models in neurorehabilitation. Medical and Biological Sciences, 2013, 27(1):19-26.

Mikołajewska E., Mikołajewski D. Computational approach to neural plasticity of nervous system on system level. Journal of Health Sciences (J Health Sci) 2012; (2)4: 39 - 47.

Mikołajewska E., Mikołajewski D. Role of brainstem within human body systems – computational approach. Journal of Health Sciences, 2012; (2)1: 95-106.

Hirsch J. Functional neuroimaging during altered states of consciousness: how and what do we measure? Prog Brain Res. 2005;150:25-43.

Brady MC, Kelly H, Godwin J, Enderby P, Campbell P. Speech and language therapy for aphasia following stroke. Cochrane Database Syst Rev. 2016;(6):CD000425.

Tanji K. Communication disorder in chronic stage stroke patients. Rinsho Shinkeigaku. 2014;54(12):1092-4.

Baumgaertner A, Grewe T, Ziegler W, Floel A, Springer L, Martus P, Breitenstein C. FCET2EC (From controlled experimental trial to = 2 everyday communication): How effective is intensive integrative therapy for stroke-induced chronic aphasia under routine clinical conditions? A study protocol for a randomized controlled trial. Trials. 2013 Sep 23;14:308.

Young A, Gomersall T, Bowen A, ACT NoW investigators. Trial participants' experiences of early enhanced speech and language therapy after stroke compared with employed visitor support: a qualitative study nested within a randomized controlled trial. Clin Rehabil. 2013;27(2):174-82.

Waldowski K, Seniów J, Leśniak M, Iwański S, Członkowska A. Effect of low-frequency repetitive transcranial magnetic stimulation on naming abilities in early-stroke aphasic patients: a prospective, randomized, double-blind sham-controlled study. ScientificWorldJournal. 2012;2012:518568.

Bowen A, Hesketh A, Patchick E, Young A, Davies L, Vail A, Long AF, Watkins C, Wilkinson M, Pearl G, Ralph MA, Tyrrell P. Effectiveness of enhanced communication therapy in the first four months after stroke for aphasia and dysarthria: a randomised controlled trial. BMJ. 2012 Jul 13;345:e4407.

Bowen A, Hesketh A, Patchick E, Young A, Davies L, Vail A, Long A, Watkins C, Wilkinson M, Pearl G, Lambon Ralph M, Tyrrell P, ACT NoW investigators. Clinical effectiveness, cost-effectiveness and service users' perceptions of early, well-resourced communication therapy following a stroke: a randomised controlled trial (the ACT NoW Study). Health Technol Assess. 2012;16(26):1-160.

Greig CA, Harper R, Hirst T, Howe T, Davidson B. Barriers and facilitators to mobile phone use for people with aphasia. Top Stroke Rehabil. 2008;15(4):307-24.

Rose TA, Worrall LE, Hickson LM, Hoffmann TC. Guiding principles for printed education materials: design preferences of people with aphasia. Int J Speech Lang Pathol. 2012;14(1):11-23.

Rose TA, Worrall LE, Hickson LM, Hoffmann TC. Aphasia friendly written health information: content and design characteristics. Int J Speech Lang Pathol. 2011;13(4):335-47.

Rose T, Worrall L, Hickson L, Hoffmann T. Do people with aphasia want written stroke and aphasia information? A verbal survey exploring preferences for when and how to provide stroke and aphasia information. Top Stroke Rehabil. 2010;17(2):79-98.

Forgacs PB, Conte MM, Fridman EA, Voss HU, Victor JD, Schiff ND. Preservation of electroencephalographic organization in patients with impaired consciousness and imaging-based evidence of command-following. Ann Neurol. 2014;76(6):869-79.

Osborne NR, Owen AM, Fernández-Espejo D. The dissociation between command following and communication in disorders of consciousness: an fMRI study in healthy subjects. Front Hum Neurosci. 2015;9:493.

de Lange FP, Helmich RC, Toni I. Posture influences motor imagery: an fMRI study. Neuroimage. 2006;33(2):609-17.

Harrison AH, Connolly JF. Finding a way in: a review and practical evaluation of fMRI and EEG for detection and assessment in disorders of consciousness. Neurosci Biobehav Rev. 2013;37(8):1403-19.

Gosseries O, Thibaut A, Boly M, Rosanova M, Massimini M, Laureys S. Assessing consciousness in coma and related states using transcranial magnetic stimulation combined with electroencephalography. Ann Fr Anesth Reanim. 2014;33(2):65-71.

Gibson RM, Fernández-Espejo D, Gonzalez-Lara LE, Kwan BY, Lee DH, Owen AM, Cruse D. Multiple tasks and neuroimaging modalities increase the likelihood of detecting covert awareness in patients with disorders of consciousness. Front Hum Neurosci. 2014;8:950.

Cruse D, Chennu S, Chatelle C, Fernández-Espejo D, Bekinschtein TA, Pickard JD, Laureys S, Owen AM. Relationship between etiology and covert cognition in the minimally conscious state. Neurology. 2012;78(11):816-22.

Lehembre R, Gosseries O, Lugo Z, Jedidi Z, Chatelle C, Sadzot B, Laureys S, Noirhomme Q. Electrophysiological investigations of brain function in coma, vegetative and minimally conscious patients. Arch Ital Biol. 2012;150(2-3):122-39.

Fernández-Espejo D, Rossit S, Owen AM. A Thalamocortical Mechanism for the Absence of Overt Motor Behavior in Covertly Aware Patients. JAMA Neurol. 2015;72(12):1442-50.

Burianová H, Marstaller L, Sowman P, Tesan G, Rich AN, Williams M, Savage G, Johnson BW. Multimodal functional imaging of motor imagery using a novel paradigm. Neuroimage. 2013;71:50-8.

Williams SE, Cooley SJ, Cumming J. Layered stimulus response training improves motor imagery ability and movement execution. J Sport Exerc Psychol. 2013;35(1):60-71.

Gosseries O, Laureys S. Current knowledge on severe acquired brain injury with disorders of consciousness. Brain Inj. 2014;28(9):1139-40.

Peterson A, Cruse D, Naci L, Weijer C, Owen AM. Risk, diagnostic error, and the clinical science of consciousness. Neuroimage Clin. 2015;7:588-97.

Prokopowicz P., Mikołajewski D. Fuzzy-based computational simulations of brain functions – preliminary concept. Bio-Algorithms and Med-Systems 2016; DOI: 10.1515/bams-2016-0009.

Mikołajewska E., Mikołajewski D. Ethical considerations in wider use of brain-computer interfaces in patients with neurological deficits. Central European Journal of Medicine, 2013b; 8(6):720-724.

Mikołajewska E., Mikołajewski D. Neuroprostheses for increasing disabled patients' mobility and control. Advances in Clinical and Experimental Medicine 2012c; 21(2):263-272.

Mikołajewska E., Mikołajewski D. The prospects of brain-computer application in children. Central European Journal of Medicine, 2014; 9(1):74-79.

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