The MultiSensory Group at STEPS Rehabilitation

In April 2023, the STEPS Speech and Language Therapy team, together with our Neurologic Music Therapist, created a new and innovative Multisensory Group for clients in a PDOC (Prolonged Disorder of Consciousness) state.

PDOC refers to individuals who remain in a coma, vegetative state or in a minimally conscious state +/- following a severe brain injury. The main aim of the group was to provide an enriched and immersive multisensory environment to provide stimulation and interaction for both assessment and quality of life purposes. The use of structured and meaningful stimuli delivered to multiple sensory channels in an integrated and simultaneous manner, also aimed to promote client’s arousal, behavioural responsiveness, and cognitive processing. 

Each multisensory group session focuses on a core, fun and familiar theme. Core themes that have been included so far have been coffee shop, gaming, cinema, nightclub, funfair, beach, football and Halloween. 

During a typical session, one themed sensory stimulus is delivered synonymously amongst the group, creating a shared and meaningful experience. Following inspiration from (Moattari et al., 2016), the group begins with an awakening and orientation which involves gently calling each client’s name with musical accompaniment introducing the therapist and each client and orientating to room and date. This is followed by auditory, tactile, visual/motor and finally, olfactory (smell) and gustatory (taste) stimulation.

Multisensory stimulation of all sensory input is then delivered simultaneously at the end of the session to truly emulate the experience clients would have had in line with the specific chosen theme. Research suggests that one’s attention orients more easily towards stimuli with multisensory properties, and that this happens automatically (Talsma et al., 2010). 

The ’coffee shop’ theme involved creating an environment in which slow background jazz music and people chatting provided auditory stimulation. A coffee shop screen saver and picture menus provided visual input. The STEPS kitchen team kindly provided fresh coffee, hot chocolate, and various flavoured teas.

These not only provided olfactory stimulation for clients to smell but they could also be aerated with micro air bubbles using Biozoon to create a lightweight airy foam allowing our clients who were nil by mouth an opportunity to taste these flavours in a safe and low risk manner whilst simultaneously providing swallow stimulation. Biscuit crumbs, warm mugs, coffee beans and cake were used for tactile stimulation. Clients could be assisted through facilitated movement to touch, smell, watch, listen and taste experiencing the multiple elements of the coffee shop themed stimuli.

The ‘Nightclub’ theme involved creating an environment in which disco lights, glow sticks and LED tambourines provided visual stimulation. Clubland music and familiar music to the client’s provided auditory stimulation. The client’s personal deodorants and aftershaves were introduced due to their familiarity and emotional saliency for olfactory stimulation. This was particularly important as studies have shown that sensory processing is enhanced by emotion (Vuilleumier, 2005). Alcohol free gin, beer and soft drinks were used with Biozoon to provide gustatory input. Hair gel was used along with cold cans and bottles of drink as tactile stimulation. 

Structured sensory activities carried out within the group have aimed to promote arousal and an increase in responses from clients. In order to measure positive change in the presentation of clients the team have used a variety of measures to capture this. The therapists have used an informal WHIM (Wessex Head Injury Matrix) assessment. This has provided a framework of observation covering an individual’s level of responsiveness and interaction with their environment with regards to arousal level, concentration, visual consciousness, communication, cognition, and social behaviours that occur spontaneously or in response to stimulation (Schnakers, 2012).

It has been possible to track the total number of responses observed within each session and track the highest level of response observed within each session for each client. This has determined any significant changes in level of responsiveness or specific patterns in responses to familiar themes.

The therapists have devised an informal sensory rating scale (ISRS) to monitor change and highlight consistent sensory strengths, which have then been useful in informing communication guidelines and person-centred care for clients. 

GSR has also started to be explored within the Multisensory Group sessions with the STEPS Solution Focused Hypnotherapist Jess Sheppy. GSR is a measurement method based on bio-electrical conductance. The GSR monitor applies a small electrical current to the skin that measures the skin conductance of the perspiration glands below the threshold of self-perception. Results so far from the GSR have shown that there have been increases/decreases in arousal and emotional responses linked to some sensory stimuli. 

Annie Forde, Specialist Speech and Language Therapist, said: “It’s been such a rewarding part of my role, to support setting up such an innovative and creative group, it gives our clients opportunities to engage with previous interests and experiences and to see their positive responses to this is truly fantastic.”

Rebekah Keenan, Neurologic Music Therapist, said: “It has been a pleasure to be a part of this new, creative, sensory and interdisciplinary approach to therapeutic intervention for clients in PDOC. Our attempts to find innovative ways of measuring progress and evidencing responses from our clients has been challenging but amazing to see!”

Jess Sheppy, Solution Focused Hypnotherapist, said: “It’s been fascinating to see some of the Galvanic Skin Response (GSR) results from this wonderfully collaborative group that works so hard to personalise the experience for our clients.”

Family involvement has been encouraged and been a successful part of the Multisensory Group. The group provides an opportunity for clients to engage in a large array of activities with their loved ones. There is nothing more familiar than the voice or company of a family member, someone the client has known for their entire life, and we never underestimate the impact that this can have on a client’s responses. Having feedback and recommendations from family members allows the STEPS team to ensure optimal familiarity and engagement for our clients in PDOC. Positive feedback from family members has included “favourite therapy session of the week” and “another great addition to therapy at STEPS”.

This Group is currently run weekly and is reviewed every six weeks. Further exploration of GSR is planned, further development of efficient measurement of responses and analysis of the informal sensory rating scale is now needed.

It has been exciting to be a part of a new innovative and interdisciplinary group. It is wonderful to see patterns and change in behaviour clearly highlighted!

• For more information on STEPS Rehabilitation, please visit here

References: 

• Abbate, C., Trimarchi, P. D., Basile, I., Mazzucchi, A., & Devalle, G. (2014). Sensory stimulation for patients with disorders of consciousness: from stimulation to rehabilitation. Frontiers in human neuroscience, 8, 616 https://doi.org/10.3389/fnhum.2014.00616 
• Moattari, M., Alizadeh Shirazi, F., Sharifi, N., & Zareh, N. (2016). Effects of a Sensory Stimulation by Nurses and Families on Level of Cognitive Function, and Basic Cognitive Sensory Recovery of Comatose Patients with Severe Traumatic Brain Injury: A Randomized Control Trial. Trauma monthly, 21(4), e23531. https://doi.org/10.5812/traumamon.23531 
• Schnakers, C., Chatelle, C., Demertzi, A., Majerus, S., & Laureys, S. (2012). What about pain in disorders of consciousness? The AAPS Journal, 14, 437-444. 
• Talsma, D., Senkowski, D., Soto-Faraco, S., and Woldorff, G. (2010). The multifaced interplay between attention and multisensory integration. Trends Cogn. Sci. 14, 400–410. doi: 10.1016/j.tics.2010.06.008 
• Vuilleumier, P. (2005). How brains beware: neural mechanisms of emotional attention. Trends Cogn. Sci. 9, 585–594. doi: 10.1016/j.tics.2005.10.011