Noninvasive Nerve Stimulation for Patients With Disorders of Consciousness Following a Traumatic Brain Injury (June 2013–October 2020)

Full Systematic Review Question

This systematic review addressed the question “What is the evidence for the effectiveness of interventions to improve arousal and awareness in people with a disordered state of consciousness post TBI?”

Current Theme Reported

The main theme of the article included in this systematic review brief is noninvasive nerve stimulation.

Clinical Scenario

More patients are surviving a traumatic brain injury (TBI) because of improvements in early resuscitation, interventions, and rehabilitation (Claassen et al., 2021). Increased survival is evident for patients with disorders of consciousness (DoC) following a severe TBI. DoC diagnoses include comatose, vegetative state/unresponsive wakefulness syndrome, and minimally conscious state (MCS). Neurobehavioral function outcome measures may include items that capture whether a patient has emerged from MCS. Recent practice guidelines recommend practitioners use standardized neurobehavioral assessment measures to improve diagnostic accuracy for disordered states of consciousness, identify trends in the patient’s recovery trajectory, and have effective rehabilitation care (Giacino et al., 2018). Evidence demonstrates that patients can experience meaningful functional recovery 5- and 10-yr postinjury (Hammond et al., 2019; Whyte et al., 2013). We provide the current evidence about interventions that can be provided by occupational therapy practitioners as part of treatment plans for adults with DoC. This systematic review brief focuses on noninvasive nerve stimulation interventions.

Summary of Key Findings

One study met the criteria for inclusion in this systematic review using right median nerve electrical stimulation (RMNS; Table 1). The levels of evidence used in this review are from Oxford Centre for Evidence-Based Medicine (2009).

Bottom Line for Occupational Therapy Practice

Occupational therapy practitioners treat individuals with DoC to facilitate arousal and awareness and use a variety of treatment modalities to support recovery of consciousness in individuals with DoC. RMNS has been studied for approximately 20 yr in patients with DoC, and patients have tolerated the intervention well with few adverse events. Although the article included in this review demonstrated that RMNS may lead to long-term changes in consciousness (i.e., after 6 mo), it does not support the immediate effectiveness of RMNS to improve arousal and awareness in patients with DoC when used in isolation from other interventions.

Future reviews should continue to include evidence for RMNS to better guide occupational therapy practitioners. RMNS could be explored as a preparatory tool to facilitate occupational performance and participation. However, the dosing of RMNS in this study (i.e., 8 hr per day) may be challenging to implement in a person’s overall plan of care and may require more complex care coordination between the multidisciplinary care team. RMNS has the potential to increase a person’s capacity for engagement with their immediate surroundings during more meaningful therapeutic interventions that match their occupational profile and that are client centered. Therefore, occupational therapy practitioners could consider using RMNS as part of a comprehensive plan of care for patients with DoC.