Mindful medicine to communicate with coma patients

Artist’s 3D rendering of electric impulses traveling through neurons

Mindful medicine to communicate with coma patients

Western University’s Adrian Owen uses brain imaging to communicate with patients in a vegetative state to better determine how aware they are
January 19, 2016

It was a late summer evening in 2013 when Juan Torres of Oakville, Ont. walked home from a friend’s place a few blocks away, ate some leftover dinner prepared by his mother Margarita Perez, and went to bed. Perez was up early the next morning and — as any mother would do — peeked in on her son before running off to a university class. To her horror, Torres’s face was blue — he had vomited and asphyxiated during the night. In the ambulance ride to hospital, paramedics were unable to intubate Torres. By the time the 19-year-old arrived at the ER department, he was in a coma, his brain starved of oxygen. Kept alive by life support, the prognosis was grim. “The doctors said there was no way he was coming back,” Perez says.

Perez refused to accept her son’s fate. Several days after the accident, with Torres in the Intensive Care Unit and still on life support, she read about the groundbreaking brain-injury research being carried out at the University of Western Ontario’s Brain and Mind Institute in London under the direction of neuroscientist Adrian Owen. The institute studies residual brain function in patients who are in a coma or vegetative state. Perez contacted the research group to ask if her son could be included as a patient.

Owen’s team arranged for Torres to travel to Western to undergo functional magnetic resonance imaging (fMRI). The scan measures brain activity by detecting changes associated with blood flow. Although Torres appeared unresponsive and unconscious, the fMRI detected brain activity in response to stimulation. “It gave us hope and the strength to continue,” Perez says.

The Brain and Mind Institute is considered one of the world’s top centres for innovation in neuroscience. In 2010, Owen was awarded the $10 million Canada Excellence Research Chair in Cognitive Neuroscience and Imaging at the institute. Trained in the United Kingdom as a psychologist, Owen undertook three years of postdoc work, starting in 1992, in neuroscience at McGill University’s Montreal Neurological Institute. After returning to the UK, Owen held such positions as senior scientist and assistant director at the Medical Research Council’s Cognition and Brain Sciences Unit and researcher at the Wolfson Brain Imaging Centre at the University of Cambridge.

Owen points to a remarkable statistic: one in five people with severe brain injuries who are in a vegetative state have some level of consciousness; they are aware of their surroundings but unable to react. Often, patients fall into a vegetative state following a coma brought on by illness or trauma, such as a car accident or assault. To the untrained eye, a coma patient looks like they are asleep. Someone in a vegetative state, however, typically has roaming eye movement and distinct sleep and wake cycles. “The key thing is, they don’t respond to any form of external stimulation,” Owen says.

Owen’s most famous breakthrough came several years ago when he asked a vegetative patient undergoing an fMRI to imagine playing tennis. This activated a specific area of the brain. Moreover, the pattern was identical to that in a healthy individual. This allowed Owen to elicit “yes” or “no” answers from patients by asking them to think about playing tennis when they wanted to communicate a response. Opening a line of communication with a vegetative patient significantly alters therapeutic strategies. “We try to make them happier and make the situation more comfortable,” Owen says.

Today, Owen has about 40 patients, most of them in Ontario in care centres, hospitals or private residences. Thanks to financial support from the Canada Foundation for Innovation (CFI) Owen is able to take the laboratory to them in his EEJeep full of electroencephalogram (EEG) equipment. (Due to logistical or physical limitations, patients often can’t travel to London for fMRI testing.) An EEG detects electrical activity in the brain via electrodes that are attached to the scalp, facilitating testing on a vegetative patient to determine levels of consciousness. “We plug the patients in and test them and bring the data back,” Owen says.

The CFI awarded Owen $1.6 million in 2013 to support his research. In addition to the EEJeep, CFI funds have been channelled into the development of a sleep laboratory with four bedrooms containing EEG equipment and infrared cameras for monitoring brain activity in normal individuals. “Sleep is a very good way of looking at alterations in consciousness in an noninvasive manner,” Owen says. “By studying the healthy brain, it tells us an awful lot about disorders of consciousness.”

Ultimately, the purpose of the studies is not to find a treatment but to determine a prognosis. By establishing which patients are the most likely to recover, limited healthcare resources can be focused on these individuals, Owen says.

Owen’s scope of research at the Brain and Mind Institute has broadened to include the study of cognitive function in university football players who receive, on average, 400 hits to the head during a season. He is also developing an interface that will allow some vegetative patients to control a computer via eye movements.

For Owen, the greatest satisfaction comes when a patient improves. Perez — strengthened by the revelation that her son’s brain was responding, put him into intensive therapies to help him regain brain function. Today, at 21, Torres is a general arts and science student at Sheridan College in Oakville. He uses a wheelchair but is slowly regaining the ability to walk. Chillingly, Torres recalls the initial testing by Owen’s team and even the questions he was asked — at a time when the doctors had written him off. It’s a key lesson for the medical profession, says Perez. Just because someone isn’t reacting “doesn’t mean the brain isn’t responding.”