That 'facilitated communication' isn't mentioned in this article is worrying. How were the vegetative people communicating, how was it observed and recorded, and how conscious were the experimenters of (possibly subconscious) mistakes in the past related to the interpretation of slight movements from the disabled or vegetative as communication?
"At the beginning and at the end of our trials, we tried to make normal conversation with Houben, and the FC seemed to work perfectly fine, producing intelligible and sometimes even elaborate sentences. In one test, we asked the facilitator to leave the room while we showed Houben a large printed word, which we read aloud to him several times. The facilitator was then allowed to return and assist Mr. Houben in giving the word back to us. Although a well-formed word, the resulting answer was completely wrong. We tried the same test with a large and simple drawing, which yielded identical results. In another test, we shielded the keyboard from the facilitator’s view in the midst of an answer. Immediately, the typing changed into gibberish and soon halted completely"
Bizarre. What if we can fully rouse patients with this treatment, but only temporarily? Imagine being dependent on a daily morning tCDS treatment to wake up every day. Maybe this will be incorporated into an implantable device, like a pacemaker for the brain (not in the sense of providing periodic pulses, but rather in the sense of being required for normal functionality).
There's actually precedent for that. [1] Uses there include epilepsy, Parkinson's and depression treatment. But extending beyond that, my search also found this [2], for Alzheimer's treatment.
The Alzheimer's bit - well, it's an interesting story. It's always a brave cowboy surgeon that even thinks about operating on an Alzheimer's brain for a number of reasons - safety, brain-wide neurodegeneration (thus not immediately obvious how something focused like surgery can help), poor cognitive baseline, etc.
The group that's probably the furthest along is the Toronto group - they tend to be pretty liberal about where to implant electrodes, and are always looking for new indications to implant stimulators (i.e. generate new IP, etc). They were initially looking to stick the thing into the hypothalamus to control weight gain, since everyone in north america is overweight and there's a huge market.
Well, turns out when they turn the thing on, the guy suddenly remembers every sexual encounter he's had since puberty in vivid detail.
Hence the pivot to Alzheimer's, with at least 2 pilot studies done w/ ~40 subjects using the currently available Medtronic Inc devices, and a new biotech startup.
The effects so far are modest - essentially the subjects deteriorated but more slowly than expected. No one suddenly started remembering things like they could when they were younger...
Yes, I vaguely remember hearing about "brain pacemakers" before, thank you for reminding me. But I'm using the term a little more metaphorically: just like a patient's heart might just stop without a pacemaker, in this case the patient would lose consciousness if the "brain pacemaker" was deactivated. To put it more bluntly, imagine that you were revived from a vegetative state, but your consciousness now effectively has an on/off switch.
Well, the Parkinson's thing isn't all that complicated - simple wire w/ ~ 1.5mm electrode sending out a 130Hz square wave at ~ 3 volts. It's been FDA approved for over a decade now, and ~100k implants have been done worldwide.
The interesting part is that no one knows why it works as well as it has.
tDCS, and TMS, on the other hand, have barely measurable effects or widely variable effects, and no one has really figured out how to make them practical. Useful for all sorts of psych papers and hypothesis generation, though.
It's certainly a great reminder that I should (as should everyone) make a living will.
If you ever end up in a persistent vegetative state, it's grueling for your family & loved ones. We now have the tech to keep you sort-of alive for many years, but it's not cheap, of course.
There have been ridiculous controversies in the US (see http://en.wikipedia.org/wiki/Terri_Schiavo_case for a good example) about families that have decided (with the support of medical professionals) to pull the plug after years of suffering... and there may be protests from the devout (because to some people, any action or explicit inaction that causes a life to end is murder), political interference all the way up to high levels, etc..
It's also somewhat sad that if it's time to give up on restoring a person to working order, the ways of doing that may be limited to somewhat slow & cruel methods (like removing a feeding tube) rather than more humane methods, due to the legal terrain.
There's a certain level of brain damage from which it's not possible to recover a functional person; it's hard to draw that line (see OP for emphasis on that), but it's a line that people in real life are obligated to draw on a regular basis.
If you make a living will that specifies that you do not wish to be kept on life support if your brain activity is below X for Y time (a bit of research required here), you can save the people you leave behind a great deal of heartache by not foisting the decision on them.
Removing a feeding tube, when consistent with the patient's wishes, is not cruel; rather, when appropriate, it is one of the most humane ways to permit a dead or dying brain's body to die.
It's not exactly cruel, but it's also not exactly the most pleasant way to die. We recently pulled a patient's feeding tube (in accordance with her own wishes - she had terminal cancer, and had been able to see the end coming for a while), and it took her a full freaking eighteen days to die on no sustenance but a single cup of water someone gave her on day six. We obviously had the poor woman on a morphine pump the whole time, so she was too out of it most of the time to suffer much, but it's not a perfect system - she kept having moments where she'd become more awake and agitated, and I did feel like she was experiencing some suffering in those moments during our best efforts.
Coincidentally at the same time, I had to have my cat put to sleep. The vet came to my house, he received a single injection, and then he peacefully fell asleep in my arms without so much as a twitch. The entire process took not five minutes altogether. I know which way of dying I'd prefer, if it was my terminally ill body at stake.
Her parents wanted to keep feeding her while her husband fought to remove the feeding tube and prevent anyone from feeding her by mouth.
Conveniently for Michael, Terri was allowed to starve to death and he was free to spend whatever remained of the 2 million dollar medical malpractice judgement on himself, his new consort and their children.
His consort? Sheesh, I guess you still have pretty strong opinions about that case.
I still don't know most of these details, and have forgotten most of what I learned at the time, and honestly that's for the better. It's none of my friggin' business, except that it highlighted some serious problems in the US legal system. And we could have learned about that problem without ever hearing the name "Terri Schiavo" or knowing anything about the personal lives of her & her family.
Until the problems are fixed (if they can be), it's important to make a living will. It shouldn't be left to your husband and parents (and the news anchors, and higher elected officials of your country) to battle each other over who has more right to say what should happen to your brainless body.
Make sure the people who need to know understand roughly what you want, and who you trust to make decisions on your behalf about palliative care, life-prolonging treatments, etc.. Google has lots of advice, free templates, etc..
Wikipedia says Terri was brain-dead for 15 years before she finally died. I don't think I know anyone who'd want their body kept alive that long. I know I would not.
Yes, I still get very angry about that case. We watched the legal system assist her husband in euthanizing her.
Saying that Ms. Schiavo was "brain dead" is an inaccurate description. Terri was severely brain damaged. She was in a persistent vegetative state. She exhibited a profound loss of brain mass. She would have never recovered but she wasn't brain dead either.
Brain dead people don't react to their mother's voice. Terri did.
Brain dead people don't track moving object. Terri did.
It's not like she was on life support. They gave her food and water through a tube. She breathed on her own and her heart beat on its own without any external assistance.
She wasn't allowed to die; she was starved to death and again, that makes me angry.
I'm not sure reading the wikipedia entry is the best way to get info on a case; but from what I understand based on the autopsy, etc., the majority of her brain had been destroyed (simply liquid in the CT scan), and while she had enough left to breath and have her heart beat, she didn't have enough for, say, a swallow reflex.
There was apparently 6 hours of video that her parents cut down to about 6 minutes that seemed to show her reacting to her mother; but the judge who watched the whole thing didn't have that impression (and the majority of the doctors evaluating it also said she was in a typical persistent vegetative state).
Maybe she did have enough brain left to occasionally have some low level of awareness? I can't pretend to know.
But if I were in that state, I would certainly not have wanted to be kept alive as long as she was; I would want to be euthanized. Perhaps you would not, and I certainly don't know what Terri would have wanted.
But that's my point, really -- people have different ideas on how to make these decisions, and it shouldn't have been left in the hands of her husband, family, etc..
If my wife wants to move on with her life -- remarry, whatever -- and I'm in a state like Terri Schiavo was, I sure as hell don't want it to be her decision whether I live or die, based on vague memories of what I've said in the past. I'd far rather my wishes were clear, and she could let me go with as little trauma as possible.
Well, not really. The treatment makes them twitch an eyelid a little more often than without brain zapping. Whether that's a quality of life you'd want still needs to be deliberated by all those involved...
Here, it's not about whether their current quality of life is good or not (obviously not), but about whether there's hope for eventual recovery. Treatments like this suggest there could be.
That is the most optimistic possible interpretation of this research.
Sure, it's possible this line of research could lead to recovery, but the idea that the brain is "on pause" while in a persistent vegetative state and would be capable of returning to normal function is probably not reality.
In these cases, it's important to define recovery - in a lot of these cases, brain is dead, and dead is dead. Sometimes, the rest of the brain is plastic enough to "reroute"so you get something back, but most of these cases, to "recover", you'd essentially have to build a new brain...
Keep in mind TDCS isn't a fancy brain machine interface that's intelligently interacting with neurons, it's just dumb direct current that's being sent into tissue...
I think the overall line of research certainly is worthwhile pursuing, just that this specific tDCS project may be being overhyped in just how much it means...
You don't pull the plug on those in a vegetative state. They have brain activity and a functioning brain stem -- generally they're just on a feeding tube.
Ideally there would be some sort of advanced directive, living will, etc. Being on a breathing machine and feeding tube is pretty terrible...a lot of people would beg to pull the plug...
> An autopsy on Terri Schiavo backed her husband’s contention that she was in a persistent vegetative state, finding that she had massive and irreversible brain damage and was blind
What's a real, possible alternative? If consciousness is not something that arises out of a multiplicity of relatively simple interactions, then is the alternative that consciousness is unrelated to the multiplicity of relatively simple interactions but by sheer coincidence vanishes when those interactions are disrupted?
First, I don't know which is the difference/connection between real and possible alternatives. By real you mean plausible?
Secondly, consciousness goes away even though those many _relatively simple_ interactions are still there. So, I'd say, that we don't really know for sure that consciousness is not there when worms are eating our brains.
Consciousness is a subjective phenomenon. That's what makes it impossible to study directly, without relying on reports. And that's what separates it from those _relatively simple_ interactions which we can model and study experimentally.
I kind of like that idea. Sort of like how Tomb Raider's ability to express itself vanishes when you turn off the Playstation. Laura continues to proceed through the dungeon, but we just can't see her.
It does not. If I think of something sad, molecules flow through my body. If I eat icecream, I remember something sad. The problem of mental causation. Unsolved. There're other problems, just as deep.
Physical causation in on one side of the deep. Phenomenal experiences are on the other side.
I found it interesting that the article mentions amantadine. I suffered a mild traumatic brain injury with post-concussion syndrome whose effects were persisting for quite a long time. While vestibular therapy made a big difference, once that treatment plateaued I started taking amantadine -- it had been suggested by my doctor before, but I'm a stubborn person. The difference that amantadine made in terms of my concussion was significant.
My migraines almost completely vanished, but more importantly I had the cognitive energy to do things that had been impossible for many months, such as programming and playing my musical instruments. I had to take it slow at first, but the difference amantadine made was truly remarkable.
It's not fully understood how this drug works, especially considering that it was originally used as an anti-flu medicine. Furthermore, my understanding is that it was no longer used in treating Parkinsons. But it's one of the few drugs that seems to have an effect in people suffering from post-concussion syndrome. A cousin of mine who also suffered from pretty serious post-concussion syndrome likewise had good results with amantadine.
It should be noted that the use of amantadine is controversial in concussion treatment. From what I've heard, some patients don't get much benefit, and the effects tend to wear off over time. Also, it caused me to have problems with insomnia, which were mostly addressed through sleep hygiene and melatonin. But I thought that I'd share my experience here, as this experience helped me to understand just how physical our mind is, and how there are likely a variety of avenues for helping the brain when it is damaged.
> Guillaume Herbet and colleagues describe the case of a 45 year old man in whom electrical stimulation of a particular spot in the brain “induced a dramatic alteration of conscious experience in a highly reproducible manner.”
Basically, when they zapped a certain point in his brain, it sent him into some kind of dream state. Very interesting.
The problem is the outcome measures for these sort of things are always kind of murky. "Signs of Responsiveness Not Previously Seen Before Intervention" might mean more eye twitching than average, etc. These aren't people who suddenly wake up and start talking after tDCS
I guess the next step is to set up blind studies, where one doctor sets up the apparatus for either a real or sham treatment, and then leaves the room, then another doctor comes in with the family and runs the treatment without knowing which treatment is being administered.
Alternatively, the treatment is administered (or not) by a second doctor in another room who can't communicate with those in the room.
Just so we're clear: when you say "electric shock therapy" you're talking about electroconvulsive therapy, which uses a strong shock to induce a seizure (under anaesthesia). It's actually the seizure itself which is therapeutic, which should give you an idea of the severity of the conditions it's used to treat: ECT is a last-resort treatment which can be lifesaving for severe depression, schizophrenia, or catatonia which are unresponsive to medication. There are less extreme alternatives being studied, but as of today ECT is still the magic bullet in some severe cases.
Anyway, this article is not about ECT, but transcranial direct current stimulation. tCDS is a completely different concept that uses much lower voltage, applied continuously in the direction of neuron activation, to promote activity and possibly growth. It's been used by healthy individuals to try to boost cognition, and it's certainly exciting to hear it may have real therapeutic indications as well.
The sample size was 55. 15 showed sign of response. I don't know the probabilities, but that's probably greater than the probability of response without treatment, with statistical significance. Obviously, you'd have to know the exact details to gauge its significance -- I'm sure those will be in the paper.
It depends on what the prior probability of them waking up without intervention was as to its significance. Statistical significance is a function of both frequency of effect and magnitude of effect.
edit:
http://theness.com/neurologicablog/index.php/man-in-coma-23-...
http://www.skepdic.com/cleverlinda.html