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What can I do to help my son to emerge more?

My son was hit by a car on April 9, 2020. He is considered minimally conscious to conscious. He appears very aware with lots of tracking and some responses. Every part of his brain was injured, but not none were injured a lot. He can't speak and doesn't move much, but he is not paralyzed. He turned 30 while in a coma and was in excellent health and super physically fit at the time he was hit. The doctors believed he would walk out of the hospital. He will use "yes" or "no" buttons a little. He can point to correct objects and photos when asked.

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Division Director PM&R

Answer transcribed from Brightway's interview with Dr. Thomas Franz:

Well, this question really covers a lot of ground. The most common type of brain injury is what's called a diffuse axonal injury, and when this person describes the injury as all the parts of the brain were injured a little, but none of them a lot, they're most likely describing that diffuse axonal brain injury.

The brain can be thought of as as a biologic computer. The cells are not like your skin cells, which are kind of like bricks that just do their job because they're stacked up against each other. A cell in your frontal area might need to communicate with the other side or all the way back to your brain stem. And these long fibers that are also part of the cell are very easily damaged by the kind of forces that might occur in a fall or a motor vehicle accident, or or even being tackled or, of course, boxing and being struck or being assaulted and being struck on the head. They're also very sensitive to shock waves like explosions, so if you were in the military and somebody set off an explosion near you, the shock wave that is transmitted through the air can do the damage.

But the point is when you basically tear up the wiring to the computer, even though the individual cells may largely survive, the computer can't function very well. In milder cases like concussion, maybe the processing is slowed or more areas of the brain have to be called upon to do the work, or the areas of the brain that need to communicate really can't communicate. So unfortunately, there's probably more damage or the sum total of the damage throughout the brain - even though no one area is really badly damaged - is probably pretty significant in this person's case.

The other thing I will mention is that there are cases where the parts of the brain stem that tell you to wake up and stay alert can be damaged all by themselves. Those connections can be damaged, and then basically that wake-up call that everybody's experienced - of being sound asleep and there's a loud noise and they're immediately awake - because there's a part of your brain that's always listening, always monitoring the environment even at an unconscious level. That's also the part of the brain that tells you to wake up in the morning and when it starts to be dark out tells you to go to sleep at night. If that is disconnected in some way, if those fibers are disrupted there, those wake-up calls never get through. The rest of the brain could be relatively intact and the person will remain comatose. I don't mean to turn this into a neuroanatomy lesson, but the point is there's an awful lot going on in a case like this usually.

Now, what can be done trying to wake the person up is usually a combination of environment - trying to establish a normal day-night cycle - and also stimulation - talking to the person, giving them normal sensation as much as possible, like touch.

But it often requires medication, and stimulant medications can be used to make the person more alert.

There are even studies that have been done and are ongoing where attempts are made to use the same type of electrical stimulators that are used - for example in severe Parkinson's disease or other conditions - to go into those areas of the brain that help keep us awake and alert and and try to stimulate them to function. The ones that have really been studied the most are forms of deep brain electrical stimulation. Now, there are some interesting papers on light therapy, but I've seen those papers, that information really lends itself more to mild to moderate brain injury. If somebody's in a minimally conscious state, that by definition is a more severe brain injury and light therapy probably isn't going to be effective at least as we currently do it. But, there are always new things being developed. There may be some interesting developments there as well.

There was a period of time in the early nineties where coma stim was very popular. They would blast horns at people and put pepper on their tongue, and poke and prod and all in a hope that all that sensory input would wake them up. That really has never been shown to be very effective by itself. But establishing normal sensation, normal sleep-wake cycles, has clearly been shown to be very helpful.

So there there are some things that can be done starting from the very simple things with the environment escalating the medication and then potentially, even working with a neurosurgeon on some of the latest technologies that have been developed.