Sensory stimulation is intended to promote awakening and enhance the rehabilitative potential of coma patients. Protocols may involve stimulation of any or all of the following senses: visual, auditory, olfactory, gustatory, cutaneous, and kinesthetic. Various stimuli may be used for each sense. Protocols may differ with respect to who performs the stimulation and where. Professionals include nurses, occupational therapists, physical therapists, and speech-language therapists. In some cases, family members may be trained in the techniques and are given primary responsibility for providing the therapy. Treatment may be delivered in the hospital, the patient’s home, or a nursing home.

Sensory stimulation for coma patients is considered investigational.

There are no specific CPT codes for coma stimulation. Coma stimulation may be billed using the CPT codes listed below.

BlueCard/National Account Issues

Sensory stimulation for coma may be billed as a physical therapy service.

When sensory stimulation is provided by nurses in an inpatient setting, there may be no separate charge. Separate claims may appear for types of sensory stimulation performed by physical therapists, occupational therapists, and speech therapists. Patients may also be transferred to a rehabilitation facility specifically for sensory stimulation

This policy is based in part on a 1989 TEC Assessment that considered whether there was adequate scientific evidence to determine if sensory stimulation either led to quicker emergence from coma or improved rehabilitative potential. (1) The TEC Assessment concluded that to validate the effectiveness of coma stimulation, controlled clinical trials of comparable patients were required. The literature available in 1989 did not meet these criteria; the 5 identified studies varied greatly in focus, design, methods, and degree of detail in the study's description. Therefore, the TEC Assessment concluded that scientific data were inadequate to permit conclusions regarding the effectiveness of coma stimulation.

A literature search from 1989 to June 1998 did not identify any controlled studies of coma stimulation. The identified studies reported case series or descriptive studies of coma stimulation techniques. (2-5) In 1991, Wood and colleagues published a critique of coma stimulation. The authors pointed out that the incomplete knowledge regarding information processing in the brain-injured state does not permit a scientific or theoretical basis of coma stimulation. (6) For example, Wood reports that the brain-injured patient is constantly exposed to sensory stimulation (i.e., skin care, range of motion exercises, bowel and bladder procedures, ambient noise in an intensive care unit) aside from any specific program of sensory stimulation. In many cases, continual background stimulation may lead to habituation and thus ultimately undermine arousal.

2006 Update

A review of the peer-reviewed literature on MEDLINE for the period of 1998 through January 2006 found no controlled clinical trials. However, a Cochrane systematic review concluded that there is no reliable evidence to demonstrate that sensory stimulation in coma patients is effective. (7) Therefore, the policy statement is unchanged.

2007 Update

A search of the MEDLINE database for the period of October 2005 through January 2007 identified no additional studies. Recovery from prolonged vegetative or minimally conscious states can be a slow and variable process that is influenced by a number of factors. (8) High quality studies that control for these factors and use objective markers of recovery are lacking. Therefore, evidence remains insufficient to evaluate the efficacy of this treatment; the policy statement is unchanged.

References:

1. TEC Assessment, 1989, p 269-77.
2. Wood RL, Winkowski TB, Miller JL et al. Evaluating sensory regulation as a method to improve awareness in patients with altered states of consciousness: a pilot study. Brain Inj 1992; 6(5):411-8.
3. Mitchell S, Bradley V, Welch JL et al. Coma arousal procedure: a therapeutic intervention in the treatment of head injury. Brain Inj 1990; 4(3):273-9.
4. Hall ME, MacDonald S, Young GC. The effectiveness of directed multisensory stimulation versus non-directed stimulation in comatose CHI patients: pilot study of a single subject design. Brain Inj 1992; 6(5):435-45.
5. Davis AE, White JJ. Innovative sensory input for the comatose brain-injured patient. Crit Care Nurs Clin North Am 1995; 7(2):351-61.
6. Wood RL. Critical analysis of the concept of sensory stimulation for patients in vegetative states. Brain Inj 1991; 5(4):401-9.
7. Lombardi F, Taricco M, De Tanti A et al. Sensory stimulation for brain injured individuals in coma or vegetative state. Cochrane Database Syst Rev. 2002; (2):CD001427. (Also available in Clin Rehabil 2002; 16(5):464-72.)
8. Laureys S, Giacino JT, Schiff ND et al. How should functional imaging of patients with disorders of consciousness contribute to their clinical rehabilitation needs? Curr Opin Neurol 2006; 19(6):520-7.

Coma Stimulation
Sensory Stimulation for Coma Patients
Stimulation, Coma