Wednesday 14 November 2012

Brain damaged patient uses mind to tell neurologists he's not in pain

Image1A man thought to be in a permanent vegetative state for the past 12 years has communicated that he is not in any pain using only his brain, causing his neurologist to say the medical textbooks need to be rewritten.
Thirty-nine-year-old Canadian Scott Routley had been completely unresponsive following a car accident and, despite his parents insisting he communicated with them by lifting his thumb or moving his eyes, neurologists said routine physical assessments demonstrated he had a total lack of awareness.
However, using a functional magnetic resonance imaging (fMRI) technique developed in 2010 by the University of Cambridge's Medical Research Council, the Wolfson Brain Imaging Centre at Addenbrooke's hospital in Cambridge and the University of Liege, a team of neuroscientists was able to ask Routley a series of questions with yes or no answers, and receive reliable and accurate responses.
"Scott has been able to show he has a conscious, thinking mind," said Adrian Owen, who co-authored the original study and led a team investigating Routley's case at the Brain and Mind Institute, University of Western Ontario. "We have scanned him several times and his pattern of brain activity shows he is clearly choosing to answer our questions. We believe he knows who and where he is."
Patients in a vegetative state appear "awake" and exhibit involuntary reflexes such as opening their eyes, but unlike coma patients their non-communicativeness is down to severe brain damage. Owen's research proves this does not necessarily mean they do not have the ability to understand.
Owen's technique involves asking a patient a series of questions while scanning their brain using an fMRI machine, which picks up and tracks the flow of oxygen-rich blood around the brain. By watching this flow in real time, the team could track distinct changes and use this information to formulate a code -- two test scenarios were put to the patients that would eventually be used to represent "yes" or "no". For instance, when asked to imagine playing tennis healthy volunteers would exhibit activity in their premotor cortex (which relates to movement planning), and in their parahippocampal gyrus (which relates to the encoding and retrieval of memories) when asked to imagine walking around their home. If individuals are told to use the first scenario to represent "yes" and the second to represent "no", they can purposefully alter their brain activity to have something of a conversation.

When the technique was first developed, Owen and his team would put the scenarios to patients in a vegetative state to see if their brain activity would change accordingly, and then ask factual questions to see if that brain function was responsive rather than passive. As part of the corresponding study it was shown that one in five of the vegetative patients investigated could use brain function to communicate and, at one hospital, the Royal Hospital for Neurodisability in London, 43 percent of the 60 patients tested had the capacity to communicate.
Two years on, Owen and his team are finally putting this research to its best use: engaging their subjects in a meaningful way. They chose Routley because he responded so clearly to the tennis and walking test scenarios.
"Asking a patient something important to them has been our aim for many years," commented Owen. "In future we could ask what we could do to improve their quality of life. It could be simple things like the entertainment we provide or the times of day they are washed and fed." This is the first time a severely brain damaged patient has ever been able to communicate anything about their medical state. Since his physical condition has not changed however -- he is still unresponsive by technical medical standards -- the medical position on vegetative states will have to be rewritten to include Owen's technique, said his neurologist of ten years, Bryan Young.
"I was impressed and amazed that he was able to show these cognitive responses. He had the clinical picture of a typical vegetative patient and showed no spontaneous movements that looked meaningful."
Steven Graham, another patient involved in the research, proved he had made new memories by responding to say "yes", when questioned if his sister had had a daughter -- Graham's sister gave birth five years after his injury.
Although Routley's responsiveness represents the first time a severely brain damaged patient has ever been able to comment on their own feelings, Owen has so far not gone so far as to ask patients involved if they have had thoughts of ending their lives. Being able to communicate changes in care would certainly present these individuals with a great improvement in their quality of life, but it is difficult to conceive what state of mind a person would be in after being unable to communicate -- despite having the mental faculties to understand -- for over a decade. Watching Routley's response to the question, "are you in pain?" in the BBC programme, however, it is evident how incredibly emotional the outcome is for everyone in involved -- so, similarly, we cannot know what it means to Routley to be able to express this, and to let his family know.
BBC's Panorma has been following Owen and his team, as well as patients at the Royal Hospital for Neuro-disability in Putney, for more than a year as part of a programme airing 13 November at 10.35pm on BBC One, The Mind Reader: Unlocking My Voice.

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