Brain-injured man speaks after 6 years

NEW YORK - A brain-damaged man who could communicate only with slight eye or thumb movements for six years can speak again, after stimulating electrodes were placed in his brain, researchers report.

The 38-year-old also regained the ability to chew and swallow, which allows him to be spoon-fed, rather than relying on nourishment through a tube in his belly.

The man's brain was injured during an assault, he spent six years with only occasional signs of consciousness and no useful movement of his limbs. In an experiment, researchers implanted electrodes in his brain for a procedure called deep brain stimulation, which is routinely done for Parkinson's disease and some other illnesses.

They turned the electrodes on and off over six months to test their effect, and reported the results in Thursday's issue of the journal Nature. The man, who was not identified at the family's request, now has them on throughout the day.

Experts called the report exciting but cautioned that the approach must be tested in more people before its value can be known. The researchers have already begun a study of additional patients.

Before the electrodes were implanted the man was in what doctors call a "minimally conscious state." That means he showed only occasional awareness of himself and the environment. In a coma or vegetative state, by contrast, patients show no outward signs of awareness.

There are no firm statistics on how many Americans are in a minimally conscious state, but one estimate suggests 112,000 to 280,000. Doctors may try medications to improve their condition but no drugs have been firmly established as helpful.

The man described in the Nature study speaks in a breathy but audible voice, said Dr. Joseph Giacino, a co-lead author. He does not initiate conversations but can reply to others, typically with one to three words, said Giacino, of the JFK Johnson Rehabilitation Institute in Edison, N.J.

Several weeks ago he recited the first half of the Pledge of Allegiance without assistance, Giacino said.

The man also recovered some movement. He can demonstrate motions such as brushing his teeth, said study lead author Dr. Nicholas Schiff of Weill Cornell Medical College in New York. He can't actually carry out that task because the tendons in his arms contracted after years of immobility.

But the treatment has helped him, the man's mother said in a statement. "Now, my son can eat, express himself and let us know if he is in pain. He enjoys a qualify of life we never thought possible," she said.

Dr. James Bernat, a professor of neurology at Darmouth Medical School who didn't participate in the new work, called the Nature report exciting and important. Further study is needed to shed light on how many patients would respond and how to identify the minimally conscious patients with the best chance of being helped, he said.

He noted that a similar treatment did not help Terri Schiavo, the Florida woman in a vegetative state whose care triggered national controversy before her death in 2005. That's the typical outcome for electrical brain stimulation in vegetative states, he said.

Dr. Ross Zafonte of the University of Pittsburgh, who also was familiar with the study results, agreed that "we need to know more" and said the approach is "very interesting and holds great promise."

Joseph T. Giacino, Ph.D.

Area of Specialty: Neuropsychology, Dementia Treatment , Movement Disorders

Professional Appointments: Associate Director of Neuropsychology, JFK Johnson Rehabilitation Institute and the New Jersey Neuroscience Institute at JFK Medical Center , Edison , NJ

Academic Appointments: Clinical Assistant Professor, University of Medicine and Dentistry of NJ, Robert Wood Johnson Medical School, Piscataway, NJ; Assistant Professor/Adjunct Faculty Member, Seton Hall University, Department of Neuroscience, South Orange, NJ; Contributing Faculty Member, Rutgers University, Graduate School of Applied and Professional Psychology, Piscataway, NJ

Graduate Education: Doctorate, Clinical Psychology, Hofstra University , NY

Medical School : N/A

Research Interest: Dr. Giacino's clinical and research interests include diagnostic assessment, outcome prediction, treatment of disorders of consciousness, awareness and executive function. He is the primary author of the JFK Coma Recovery Scale-Revised which has been translated into six languages. He has published and lectured extensively on topics pertaining to neuropsychological and neurobehavioral sequelae of severe brain injury and maintains an active program of research. He was instrumental in establishing a case definition for the minimally conscious state and is the principal investigator for three federally-funded research studies investigating novel assessment strategies and neuromodulatory interventions designed for patients who have sustained severe brain injury.

Professional Memberships: American Congress of Rehabilitation Medicine (Fellow) Board Member, American Psychological Association, Brain Injury Association of America, Inc, National Academy of Neuropsychology (Fellow), New Jersey Neuropsychology Society

Honors and Awards: Distinguished Member Award, American Congress of Rehabilitation Medicine, 2002; Fellow, American Congress of Rehabilitation Medicine, 2004; Fellow, National Academy of Neuropsychology, 2003; Certificate of Distinguished Achievement in Psychology, Fairfield University, 1981

Representative Publications:

Giacino, J. The minimally conscious state: Defining the borders of consciousness. In: Laureys S (ed.): Progress in Brain Research, The Boundaries of Consciousness: Neurobiology and Neuropathology . Amsterdam , Elsevier , 2005;150:381-395.

Cicerone K, Dahlberg C, Malec JF, Langenbahn D, Felicetti T, Kneipp S, Ellmo W, Kalmar K, Giacino JT , Harley JP, Laatsch L, Morse P, Catanese J. Evidence-Based Cognitive Rehabilitation: Updated Review of the Literature from 1998 through 2002. Archives of Physical Medicine and Rehabilitation. 2005;86:1681-1692.

Giacino J . Diagnostic and prognostic guidelines for the vegetative and minimally conscious states. Neuropsychological Rehabilitation, 2005;15(3-4):166-174.

Kalmar K, Giacino J . The JFK Coma Recovery Scale- Revised. Neuropsychological Rehabilitation, 2005;15(3-4):454-460.

Moussouttas M, Giacino J, Papamitsakis NI. Amnestic syndrome of the subcallosal artery. Cerebrovascular Diseases, 2005;19:410-414.

Whyte J, Katz D, Long D, DiPasquale M, Polansky M, Kalmar K, Giacino J , Childs N, Mercer W, Novak P, Maurer P, Eifert B. Predictors of Outcome in Prolonged Posttraumatic Disorders of Consciousness and Assessment of Medication Effects: A Multicenter Study. Archives of Physical Medicine and Rehabilitation, 2005;86:453-462.

Schiff ND , Rodriguez-Moreno D, Kamal A, Kim KHS, Giacino J , Plum F, Hirsch J. Functional MRI reveals large scale network activation in minimally conscious patients. Neurology , 2005;64:514-523.

Giacino J , Whyte J. The vegetative and minimally conscious states: Current knowledge and remaining questions. Journal of Head Trauma Rehabilitation , 2005;20(1):30-50.

Giacino J . The vegetative and minimally conscious states: Consensus-based criteria for establishing diagnosis and prognosis. Neurorehabilitation , 2004;19(4):293-298.

Giacino JT , Kalmar K, Whyte J. The JFK Coma Recovery Scale- Revised: Measurement Characteristics and Diagnostic Utility. Archives of Physical Medicine and Rehabilitation, 2004;85(12):2020-2029 .

Giacino JT , Trott C. Rehabilitative Management of Patients with Disorders of Consciousness : Grand Rounds. Journal of Head Trauma Rehabilitation, 2004;19(3):262-273.

Schiff N, Ribary U, Rodriguez-Moreno D, Beattie B, Kronberg E, Blasberg R, Giacino J , McCagg C, Fins J, Llinas R, Plum F. Residual Cerebral Activity and Behavioral Fragments Can Remain in the Persistently Vegetative Brain. Brain , 2002;125:1210-1234.

Giacino JT , Ashwal S, Childs N, Cranford R, Jennett B, Katz DI, Kelly JP, Rosenberg JH, Whyte J, Zafonte RD , Zasler ND . The minimally conscious state: Definition and diagnostic criteria. Neurology , 2002;58:349-353.

Editorial Positions: Editorial Board: Journal of Head Trauma Rehabilitation; Ad hoc: Archives of Physical Medicine and Rehabilitation, Brain, Nature Reviews-Neuroscience and Neuropsychological Rehabilitation.

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