A 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.
http://www.wired.co.uk/news/archive/2012-11/13/vegetative-man-communicates-with-mind