Patients with traumatic brain injury (TBI) admitted to the ICU experience multiple stressors related to environmental factors, intensive therapeutic interventions, and surgery. The limited meaningful sensory stimuli of the ICU can result in sensory deprivation, while the increased lights and noise present in the ICU can result in sensory overload. These environmental conditions can lead to perceptual, cognitive, and emotional disorders and cause psychological imbalances in patients.1,2
According to studies conducted on this topic, hospitalization in the ICU is stressful to patients.3-5 Spending time in an unknown environment apart from family, such as an ICU, contributes to patients' anxiety and stress levels, consequently affecting their vital signs.1,6 In fact, ICU admission has been linked to complications such as anxiety, pain, fear of an unknown environment, hemodynamic instability (hypertension, tachycardia, and tachypnea), and reduced levels of consciousness and Glasgow Coma Scale (GCS) scores.7
Some estimated 69 million individuals experience TBI from all causes each year, with the Southeast Asian and Western Pacific regions experiencing the greatest overall burden of disease.8 Head injury following road traffic collision is more common in low- and middle-income countries, and the proportion of TBIs secondary to road traffic collision is likewise greatest in these countries. Meanwhile, the estimated incidence of TBI is highest in regions with higher-quality data, specifically in North America and Europe.8
Recent medical and technological advances and improvements in healthcare have reduced TBI-related mortality. Unfortunately, TBI-related morbidity has not improved. An estimated 5.3 million Americans alone are living today with a disability related to TBI.9
Patients with severe TBI, defined by a GCS score less than 9, are optimally managed in a specialized neurotrauma center with neurosurgical and neurocritical care support and the use of guidelines-based standardized protocols.10,11 Implementing a structured sensory stimulation program could help facilitate the recovery process in these patients and prevent sensory deprivation. This may include visual, auditory, tactile, olfactory, taste, and balance stimulation. Planned sensory stimulations should be applied in the early stages of TBI for maximum benefit.12 These noninvasive, nonpharmacologic, and cost-effective interventions can enhance medical care.13
Tactile stimulation is an intrinsic component of nursing care and is considered a foundation of patient care.14 Tactile stimulation, quiet speech, and nonverbal communication produce feelings resulting from the stimulation of tactile sensors in the skin, which are then analyzed and processed in the brain. Nonverbal communication is one of the most effective communication methods.14-17 Tactile stimulation can engender positive feelings such as relaxation, safety, and affection, as well as negative feelings such as anger and aggression.
With the goals of improving patient care and decreasing hospital length of stay, the authors conducted a study evaluating the effect of tactile stimulation on the level of consciousness and vital signs in patients with TBI admitted to the trauma ICU in the three hospitals affiliated with the Social Welfare Organization and medical universities in Qazvin, Iran. This article outlines the authors' study methods and results.
The authors conducted a literature review on previous related research. Tactile stimulation is complementary to medical treatment; general relaxation and pain relief are among its major benefits.18 Sensory stimulation activates the neural network and prevents sensory deprivation, which prolongs the recovery process.19
A study by Souri Lakie and colleagues indicated that tactile stimulation improved respiratory status and increased oxygen saturation.14
Results of a landmark study by Wilson and colleagues on the effect of monomodal and multimodal sensory stimulation in comatose patients showed no significant changes in patients who received monomodal stimulation, whereas patients receiving multimodal stimulation could open their eyes and voluntarily move their limbs.20
A study by Moattari and colleagues showed tactile stimulation could increase patients' levels of consciousness.21 Because an increased level of consciousness is considered an indicator of disease improvement process in critically ill patients, particularly those with TBI, any intervention or care that can increase the level of consciousness in such patients can improve the patient's prognosis. Onset of tactile stimulation in the first 72 hours after the injury is essential to the patient's recovery, quality of life, and long-term prognosis.22 Evidence indicated that providing regular sensory stimulation decreased the risk of sensory deprivation by reducing the duration of ICU hospitalization and stress levels.22,23
Results of a study by Fakhr-Movahedi and colleagues on the effect of touch on the vital signs of agitated patients undergoing mechanical ventilation indicated that performing tactile stimulation at the patient's wrist significantly decreased the systolic BP, heart rate, and respiratory rate; however, the stimulations had no effect on the diastolic BP or body temperature.18
In a study by Abdi and colleagues on the effect of foot massage on the level of consciousness of comatose patients with TBI, results indicated that massage increased the level of consciousness by 5 points on the GCS.24
No evidence yet indicates the hazards of sensory stimulation programs used to improve level of consciousness.25
The authors performed their own clinical trial involving 60 patients with TBI admitted to one of three trauma ICUs in Qazvin, Iran, in 2016. The authors randomly assigned 30 patients to the intervention group and the other 30 patients to the control group. Patients were informed about the study aim and assured of the confidential handling of their information. This article is the result of the author's thesis. The research was carried out in accordance with guidelines from the Qazvin University of Medical Sciences ethics committee.
Inclusion criteria included:22,26
- TBI diagnosis (subdural, epidural, intracerebral, intraventricular, and subarachnoid hemorrhage) based on the written comment of a neurosurgeon
- age 18 through 65
- absence of any underlying chronic diseases, such as diabetes (due to possible peripheral neuropathy), documented in the patient's medical record
- absence of any sensory disorders in upper extremities
- GCS score of 5 to 8
- Absence of psychological disorders, such as generalized anxiety disorder, diagnosed by a physician.
Exclusion criteria included:
- unwillingness of the patient's family to participate in the study
- patient transfer to another hospital out of Qazvin
- unexpected deterioration in level of consciousness
- simultaneous participation in a similar caregiving program, such as massage therapy.
Patients in the intervention group received tactile stimulation to the palm and wrist bilaterally for 5 minutes twice a day—at 1100 and 1700—for the first 5 days of ICU hospitalization. Patients in the control group received only routine ICU care. Five minutes before performing tactile stimulation in the intervention group, the authors measured and recorded the level of consciousness and vital signs of patients in both the intervention group and control group, including BP, heart rate, and respiratory rate, using an electronic monitoring device. The authors also measured patients' body temperatures using a tympanic thermometer and levels of consciousness using the GCS. In the intervention group, researchers then slowly encircled the patients' wrists with their fingertips without applying any pressure. They also touched the patients' hands from wrists to fingertips. Tactile stimulation was applied for a total of 5 minutes. Immediately after the intervention, level of consciousness and vital signs were measured again in both groups.6 In addition to the preintervention and postintervention measurements, the level of consciousness and vital signs of patients in both groups were taken every 2 hours, as per hospital policy.
The authors analyzed data in this study using SPSS V21.0. The authors used a paired t test to compare the status of patients in the intervention group before and after the intervention, and an independent t test to compare the results of the intervention and control groups.
Out of 60 subjects in the study, 13 (21.7%) were female and 47 (78.3%) were male. In the intervention group, 3 (10%) were female and 27 (90%) were male. In the control group, 10 (33.3%) were female and 20 (66.7%) were male.
The mean age of the patients in the intervention group was 39.1 ± 15.67 years and ranged from 21 to 75 years. The mean age of the patients in the control group was 43.87 ± 12.3 years and ranged from 71 to 91 years; according to the results of the independent t test, no significant difference was observed between the intervention and control groups.
Study results indicated that the mean GCS score of the 30 intervention group patients increased from day 2 of the intervention. According to the results of the independent t test, tactile stimulation had a positive and significant effect on the GCS score (P = .0001) and level of consciousness in the intervention group (P = .001).
The intervention group mean heart rate decreased as much as 4.47 beats per minute. The mean systolic BP in the intervention group decreased during the intervention by 9.1 mm Hg. The mean diastolic BP of the patients in the intervention group decreased during the intervention by 10.63 mm Hg. The mean respiratory rate also decreased in the intervention group by 0.6. The mean body temperature did not change in both the intervention and control groups. According to the results of the independent t test, a significant difference was observed between the groups (P < .05).
Discussion and limitations
The results of this study show that tactile stimulation increased the level of consciousness and improved vital signs in patients with severe TBI, confirming the positive effects of tactile stimulation on the level of consciousness and vital signs in patients with TBI hospitalized in the ICU. Although the use of tactile stimulation was previously evaluated in various studies in the authors' literature review, no study was found that addressed the simultaneous effect of tactile stimulation on vital signs and level of consciousness.
Limitations of the study included its small sample size and single geographic location. The authors recommend further studies on patients with different diagnoses, in different healthcare environments, and with larger sample sizes.
Tactile stimulation can increase the level of consciousness and improve vital signs of patients admitted to the ICU with severe TBI. The study results support the use of tactile stimulation as a complementary therapy and support educational programs for nursing staff on using tactile stimulation and its benefits for patient recovery.
1. Yousefi H, Naderi M, Daryabeigi R. The effect of sensory stimulation provided by family on arterial blood oxygen saturation in critical care patients. Iran J Nurs Midwifery Res
2. Goudarzi F, Basampoor S, Zakeri-Moghadam M, Faghih-Zadeh S, Rezaie F, Mohamad-Zadeh F. Changes in level of consciousness
during auditory stimulation by familiar voice in comatose patients. Iran J Nurs: Iran University Medical Sciences
3. Fleischer S, Berg A, Behrens J, et al Does an additional structured information program during the intensive care unit stay reduce anxiety in ICU patients?: a multicenter randomized controlled trial. BMC Anesthesiol
4. Marino P. Marino's The ICU Book
. 4th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2014:566.
5. de Sá Dias D, Vanessa Resende M, do Carmo Leite Machado Diniz G. Patient stress in intensive care: comparison between a coronary care unit and a general postoperative unit. Brazilian J Intensive Care
6. Zare Z, Shahsavari H, Moeini M. Effects of therapeutic touch on the vital signs
of patients before coronary artery bypass graft surgery. Iran J Nurs Midwifery Res
7. Vahedian-Azimi A, Ebadi A, Asghari Jafarabadi M, Saadat S, Ahmadi F. Effect of massage therapy on vital signs
and GCS scores of ICU patients: a randomized controlled clinical trial. Trauma Mon
8. Dewan MC, Rattani A, Gupta S. Estimating the global incidence of traumatic brain injury
. J Neurosurg
. [e-pub April 27, 2018].
10. Aghakhani N, Azami M, Jasemi M, Khoshsima M, Eghtedar S, Rahbar N. Epidemiology of Traumatic Brain Injury
in Urmia, Iran. Iran Red Crescent Med J
12. Abbasi M, Mohammadi E, Sheaykh Rezayi A. Effect of a regular family visiting program as an affective, auditory, and tactile stimulation
on the consciousness level of comatose patients with a head injury. Jpn J Nurs Sci
13. Potter PA, Perry AG, Stockert PA, Hall AM. Fundamentals of Nursing
. 8th ed. St. Louis, MO: Elsevier; 2016:643–644.
14. Souri Lakie A, Bolhasani M, Nobahar M, Mahmoudi H. The effect of touch on the arterial blood oxygen saturation in agitated patients undergoing mechanical ventilation. Iran J Crit Care Nurs
15. Memarian R. Application of Nursing Concepts and Theories
. 3rd ed. Tehran: Heydari Publishing; 2014:346.
16. Asad Zandi M. Concepts and Theories of Nursing
. 1st ed. Tehran: Heydari Publishing; 2014:409.
17. Monir Nobahar M, Bolhasani M, Fakhr-Movahedi A, Ghorban R. Effects of touch on agitation in patients under mechanical ventilation. Koomesh J
18. Fakhr-Movahedi A, Nobahar M, Bolhasani M. The effect of touch on the vital signs
of agitated patients undergoing mechanical ventilation: an interventional study. J Urmia Nursing Midwifery Faculty
19. Schnakers C, Magee WL, Harris B. Sensory stimulation and music therapy programs for treating disorders of consciousness. Front Psychol
20. Megha M, Harpreet S, Nayeem Z. Effect of frequency of multimodal coma stimulation on the consciousness levels of traumatic brain injury
comatose patients. Brain Inj
21. Moattari M, Alizadeh Shirazi F, Sharifi N, Zareh N. 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 Mon
22. Hasanzadeh F, Hoseini Azizi T, Esmaily H, Ehsaee MR. The impact of familiar sensory stimulation on level of consciousness
in patients with head injury in ICU. J North Khorasan University Medical Sciences
23. Hoseini Azizi T, Hasanzadeh F, Esmaily H, Ehsaee MR, Masoudynia M. The effect of family's supportive presence on the recovery of patients with brain injury in intensive care unit: a randomized clinical trial. J Urmia Nursing and Midwife Faculty
24. Azimian J, Abdi M, Moradi M, Alipour Heidari M, Yekeh Fallah L, Sheikhi MR. The effect of foot massage on the consciousness levels in comatose patients with brain injury hospitalized in intensive care unit (ICU): a randomised control trial. J Knowledge Health
25. Heidari Gorji MA, Araghiyansc F, Jafari H, Heidari Gorgi AM, Yazdani J. Effect of auditory stimulation on traumatic coma duration in intensive care unit of Medical Sciences University of Mazandarn, Iran. Saudi J Anaesth
26. Zolfaghari M, Eybpoosh S, Hazrati M. Effects of therapeutic touch on anxiety, vital signs
, and cardiac dysrhythmia in a sample of Iranian women undergoing cardiac catheterization: a quasi-experimental study. J Holist Nurs