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A Controlled Multi-Sensory Stimulation Therapy for Children Recovering from Severe Brain Injury

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A Controlled Multi-Sensory Stimulation Therapy for Children Recovering from Severe Brain Injury Brain Injury, July 2006; 20(8): 879–888 Snoezelen: A controlled multi-sensory stimulation therapy for children recovering from severe brain injury GILLIAN A. HOTZ1, ANDREA CASTELBLANCO1, ISABEL M. LARA1, ALYSSA D. WEISS1, ROBERT DUNCAN2, & JOHN W. KULUZ3 1DeWitt Daughtry Family Department of Surgery, Division of Trauma and Surgical Critical Care, Ryder Trauma Center, Miami, FL, USA, 2Department of Epidemiology and Public Health, and 3Department of Pediatrics, University of Miami, Miller School of Medicine, Miami, FL, USA (Received 11 May 2005; accepted 26 May 2006) Abstract Objective: To investigate the effects of Snoezelen therapy on physiological, cognitive and behavioural changes in children recovering from severe traumatic brain injury (TBI). Methods: An observational study was conducted to assess the physiological, cognitive and behavioural changes of children recovering from severe TBI while receiving Snoezelen therapy. Fifteen subjects completed the pre- and post-Snoezelen treatment measurements computed over 10 consecutive sessions. Physiological, cognitive and behavioural measures were administered. Data was collected prospectively on each session in the Snoezelen room and were analysed by calculating the difference between pre- and post-treatment measurements for each Snoezelen session. Results: Results revealed significant changes on physiological measures. Heart rates decreased for each subject in each treatment session and were found to be significant (p ¼ 0.032). Muscle tone was decreased in all the affected extremities (right upper extremity p ¼ 0.009, left upper extremity p ¼ 0.020, right lower extremity p ¼ 0.036 and left lower extremity p ¼ 0.018). Agitation levels decreased over time and the overall cognitive outcome measures showed significant improvement when comparing the beginning of treatment with the end. Conclusion: This study revealed a beneficial use of Snoezelen therapy with children recovering from severe brain injury. However, there continues to be a critical need for evidenced-based research for this patient population and others in this multi-sensory environment. Keywords: Behavioural, children, multi-sensory, Snoezelen, therapy Introduction Motor vehicle accidents involving pedestrians is the second leading cause of unintentional injury Trauma is the leading worldwide cause of death and among children under the age of 15 in motorized a major cause of disability in children. Traumatic brain injuries (TBI) occur in 85% of traumatized countries [6]. Miami-Dade County has the highest children and account for more than 50% of the incidence of paediatric pedestrian injuries and fatali- deaths in the paediatric population. Each year, more ties in the state of Florida [7]. The Ryder Trauma than 1 million children in the US sustain TBI, with Center (RTC) at University of Miami/Jackson 250 000 admitted to hospitals for treatment. Memorial Medical Center at (UM/JMMC) provides As many as 7000 die and 30 000 are permanently care to trauma victims in South Florida. The RTC disabled [1–5]. sees about 500 children and adolescents <18 years Correspondence: Gillian A. Hotz, PhD, Ryder Trauma Center # 405, 1800 NW 10th avenue, Miami, FL 33136, USA. Tel: 305-585-1258. Fax: 305-585-1263. E-mail: [email protected] ISSN 0269–9052 print/ISSN 1362–301X online ß 2006 Informa UK Ltd. DOI: 10.1080/02699050600832635 880 G. A. Hotz et al. of age per year. Of these, 50 children with application of a treatment that is tailored in intensity moderate and severe TBI are admitted per year to and frequency of stimulation to an individual’s the Paediatric Rehabilitation Unit of this hospital. threshold (consisting of auditory, visual, tactile, Recovery from paediatric brain injury entails a gustatory, olfactory and kinetic modes) in an attempt complex interplay among diverse factors, such as the to increase arousal and awareness and elicit mean- pathophysiology of the brain injury, the develop- ingful, behavioural response. The rationale is that mental stage at the time of injury, cerebral plasticity, exposure to frequent and various sensory stimula- the amount of time after the injury and the child’s tions will facilitate both dendritic growth and reserve of psychosocial resources. Dennis [8] found improve synaptic connectivity in those with damaged that some impairments in young children actually nervous systems [18, 19]. Most sensory stimulation increase in severity over time after injury. They programmes are designed to prevent sensory depri- hypothesized that early insults may limit the brain’s vation and to provide structured input in order to capacity to develop normally or may interfere with maximize a patient’s ability to process and respond the timing of neural development and that new to stimuli [21]. The ultimate goal of enriched deficits may emerge at later stages after injury. environments is to facilitate recovery of the nervous Other experts argue that the concept of cerebral system so that patients are able to process informa- plasticity of the developing brain still seems to lead tion of increasing variety and complexity. to more favourable outcomes after TBI for younger In contrast, the sensory regulation approach is age groups [9, 10]. Enhancement of plasticity is based on information processing and mediation of known to occur through both endogenous factors, reaction to sensory information with emphasis on such as the release of nerve growth factor [11, 12] enhancing selective attention by regulating the and exogenous factors such as environmental stimu- environment rather than providing high degrees of lation [8]. There is evidence that suggests that the stimulation. What both approaches have in common myelinization process as well as the synaptic plastic- is that those in minimally conscious states at some ity is influenced by functional interaction with the level are able to perceive and begin to process environment [13, 14]. Based on previous evidence, information and that external stimulation may the influence of environment stimulation can be enhance that process [22]. Therefore, to observe used as an intervention to improve motor skills and any recovery in patients with severe brain injury, cognitive function. increasing the level of arousal and attention is the Current treatments for children with severe TBI in first step on the road to recovery. the acute stages include coma stimulation or sensory Snoezelen, or controlled multi-sensory stimulation regulation programmes. These programmes try to therapy, comprises the components of a novel sensory achieve an awakening or increasing arousal level of stimulation approach. Snoezelen as an alternative the patient. Stimulation programmes have been treatment modality is gaining attention worldwide. advocated for these persons; however, reliable Hulsegge and Verheul from the Netherlands derived evidence as to their effectiveness and their concep- this term in 1975 by blending two Dutch words, tual basis has been poorly understood. Early experi- ‘sniffing’ and ‘dozing’ together, to describe a process mental evidence indicates that normal animals of controlled sensory stimulation in a non-threatening reared in enriched environments demonstrate sig- secure environment involving all sensory systems nificantly greater learning and memory skills than [23, 24]. These multi-sensory rooms contain visual, those reared in less stimulating or impoverished olfactory, auditory, vestibular and proprioceptive environments [15]. Studies of animals with brain equipment (e.g. mirror light balls, bubble tubes, lesions suggest that those cared for in environments fibre-optic cables, ball pools, aromatherapy, calming permitting greater perceptual and motor stimulation music, etc.). Once inside this environment, there are performed significantly better on general learning opportunities for stimulation of all senses. Currently, tasks than those cared for in non-enriched environ- Snoezelen has been most commonly utilized for ments [16]. A more recent study by Giza et al. [17], individuals with severe sensory impairments, studied baby rats following a fluid percussion injury autism, severe developmental and/or learning dis- reared in either a standard or enriched environment. abilities, severe and profound mental retardation, The findings confirm that early TBI has effects on dementia, chronic pain and burns [25–28]. In 1992 in experience-dependent plasticity resulting in long- the US, ‘Snoezelen’ became a registered trademark of term neurobehavioural deficits and beneficial effects FLAGHOUSE, Inc. from environmental stimulation following TBI are Snoezelen is similar to the notion of sensory dependent upon time after injury. stimulation or sensory buffet which has been studied The multi-stimulation approach such as the Coma by many investigators [25, 29]. Snoezelen environ- Recovery Programme or Coma Arousal Therapy ments are thought to facilitate relaxation, provide [18–20] is based on behaviourism. Basically, it is any enjoyment experience and inhibit behavioural Snoezelen 881 changes [30, 31]. The stimulation is believed to of alternative modalities in addition to traditional promote a sense of enjoyment and a relief from rehabilitation therapies available for care takers and tension and pressure, with consequent improvement family members to work purposefully and effectively in general behaviour. Kwok et al. [32] reported nine with children recovering from severe TBI; and functions that can be promoted in a Snoezelen room, (2) the widely held notion that Snoezelen is a including:
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