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Low Level Responsiveness TBI Patient:

Objective:

To stimulate the visual system and initiate arousal of the central nervous system. Also, to reduce the amount of visual deprivation to the patient while in a comatose state.

Activities:

  1. Pupillary Stimulation - An extremely bright light source, such as a halogen pen light, should be shined into the patient's pupil for 20 seconds followed by removal of the light source for 20 seconds. Repeat for 5 minutes 2 or 3 times daily. Therapist should watch for increase in the briskness of pupil closure when the light source is first shined into the eye. If the patient has a third nerve palsy, characterized by a fixed dilated pupil and droopy eyelid, this procedure can be helpful to allow the pupil to begin responding to stimulation.
  2. H.A.S. Card - The H.A.S. card contains a series of dots which when moved quickly, horizontally or vertically, in front of a patient, will stimulate the retinal cells giving the perception of a linear pattern. The therapist should place the card approximately 13 inches in front of the patient's eyes and quickly move the card back and forth, horizontally, then vertically for approximately 30 seconds. The therapist may observe a nystagmus (rhythmic shaking of the eyes) in response to this stimuli. This is a positive sign of a normal visual pathway.
  3. Warm/Cold Compress - If the patient has a ptosis (droopy eyelid), alternating cold/warm, wet compresses should be applied to the eye for a period of 2-3 minutes each. The alternating temperatures help to contract the levator and orbicularis muscles which help improve the patency of the third nerve signal. The therapist of a family member should also be instructed to manually lift the eyelid several times daily in order to allow light to penetrate the eye and to help free up any rigidity in the ocular muscles.
  4. Eye Counter-Rolling - With both eyes open or eyelids manually raised, the therapist should manually rotate patient's head left to right and observe a counter-rolling of the eyes in the opposite direction. Repeat the procedure moving the patient's head up and down and observe the eyes ability to counter-roll in a vertical direction. If the patient's eyes do not counter-roll, try speaking to the patient at a very close distance using your face as a fixation target and slowly begin moving the patient's face back and forth. Continue with this until some counter-rolling is noted in order to prevent a gaze palsy.
  5. Auditory Stimulation - Have a family member play music that they know the patient likes for a short period of time followed by music that they know the patient does not like. The purpose is to elicit a central nervous system response which can then make visual system responses more accessible.
  6. Prism Shift - Using high powered yoked prisms that can be easily rotated, the therapist should alternate between base left, base right, base up and base down orientations of the prisms in front of the patient for a period of no more than 5 minutes in each direction. Even on an unconscious level, the prisms will disrupt the patient's spatial perception and force the patient to make a reorientation of their visual world which provides a visual learning skill.