|Classification and external resources|
Locked-in syndrome can be caused by stroke at the level of the basilar artery denying blood to the pons, among other causes.
Locked-in syndrome, or LIS for short, is a condition in which a patient is aware and awake but cannot move or communicate verbally due to complete paralysis of nearly all voluntary muscles in the body except for the eyes. Total locked-in syndrome is a version of locked-in syndrome where the eyes are paralyzed, as well. The term for this disorder was coined by Fred Plum and Jerome Posner in 1966. Locked-in syndrome is also known as cerebromedullospinal disconnection, de-efferented state, pseudocoma, and ventral pontine syndrome.
Locked-in syndrome usually results in quadriplegia and the inability to speak in otherwise cognitively intact individuals. Those with locked-in syndrome may be able to communicate with others through coded messages by blinking or moving their eyes, which are often not affected by the paralysis. The symptoms are similar to those of sleep paralysis. Patients who have locked-in syndrome are conscious and aware, with no loss of cognitive function. They can sometimes retain proprioception and sensation throughout their bodies. Some patients may have the ability to move certain facial muscles, and most often some or all of the extraocular eye muscles. Individuals with the syndrome lack coordination between breathing and voice. This restricts them from producing voluntary sounds, though the vocal cords are not paralysed.
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Unlike persistent vegetative state, in which the upper portions of the brain are damaged and the lower portions are spared, locked-in syndrome is caused by damage to specific portions of the lower brain and brainstem, with no damage to the upper brain.
Possible causes of locked-in syndrome include:
- Traumatic brain injury
- Diseases of the circulatory system
- Medication overdose
- Damage to nerve cells, particularly destruction of the myelin sheath, caused by disease (e.g. central pontine myelinolysis secondary to rapid correction of hyponatremia)
- A stroke or brain hemorrhage, usually of the basilar artery
- Multiple Sclerosis
- Amyotrophic lateral sclerosis (aka Lou Gehrig's disease)
Neither a standard treatment nor a cure is available. Stimulation of muscle reflexes with electrodes (NMES) has been known to help patients regain some muscle function. Other courses of treatment are often symptomatic. Assistive computer interface technologies, such as Dasher in combination with eye tracking, may be used to help patients communicate. New direct brain interface mechanisms may provide future remedies; one effort in 2002 allowed a fully locked-in patient to answer yes-or-no questions. Some scientists have reported that they have developed a technique that allows locked-in patients to communicate via sniffing.
Extremely rarely does any significant motor function return. The majority of locked-in syndrome patients do not regain motor control, but devices are available to help patients communicate. Within the first four months after its onset, 90% of those with this condition die. However, some people with the condition continue to live much longer, while in exceptional cases, like that of Kerry Pink and Kate Allatt, a full spontaneous recovery may be achieved.
Parisian journalist Jean-Dominique Bauby suffered a stroke in December 1995, and, when he awoke 20 days later, he found his body was almost completely paralyzed; he could control only his left eyelid. By blinking this eye, he slowly dictated one alphabetic character at a time and, in so doing, was able over a great deal of time to write his memoir, The Diving Bell and the Butterfly. Three days after it was published in March 1997, Bauby died of pneumonia. The 2007 film The Diving Bell and the Butterfly is a screen adaptation of Bauby's memoir. Jean-Dominique was instrumental in forming the Association du Locked-In Syndrome (ALIS) in France.
Kate Allatt is a mother-of-three from Sheffield, South Yorkshire. She has successfully recovered from locked-in syndrome. Now she runs Fighting Strokes, and devotes her life to assisting those with locked-in syndrome.
In 1966, Julia Tavalaro, then aged 32, suffered two strokes and a brain hemorrhage and was sent to Goldwater Memorial Hospital on Roosevelt Island, New York. For six years, she was believed to be in a vegetative state. In 1972, a family member noticed her trying to smile after she heard a joke. After alerting doctors, a speech therapist, Arlene Kratt, discerned cognizance in her eye movements. Kratt and another therapist, Joyce Sabari, were eventually able to convince doctors she was in a locked-in state. After learning to communicate with eye blinks in response to letters being pointed to on an alphabet board, she became a poet and author. Eventually, she gained the ability to move her head enough to touch a switch with her cheek, which operated a motorized wheelchair and a computer. She gained national attention in 1995 when the Los Angeles Times published her life story. It was republished by Newsday on Long Island and in other newspapers across the country. She died in 2003 at the age of 68.
In 1983, Rom Houben survived a near-fatal car crash and was diagnosed as being in a vegetative state. Twenty-three years later, using "modern brain imaging techniques and equipment", doctors revised his diagnosis to locked-in syndrome. He was initially reported as communicating by typing into a keyboard with his right hand, though the presence of a facilitator to move his hand attracted sharp criticism and strong doubts that Houben's communications were authentic.
In early 2010, Dr. Steven Laureys, Houben's neurologist, admitted that subsequent tests had demonstrated Houben had not actually been communicating via the facilitator, and Der Spiegel, which had originally "quoted" many of Houben's facilitated statements, retracted those quotes as being inauthentic. Laureys maintained the MRI data that had led him to diagnose Houben as locked-in still suggested he was conscious.
In 1993, Graham Miles, originally from Sanderstead, London Borough of Croydon, suffered a stroke after which he could not move any part of his body except his eyes. His condition improved gradually, to the point that in 2010 he was able to walk with two sticks and drive a car.
Christine Waddell is Britain's longest survivor of locked-in syndrome, leaving her in a state of constant paralysis, but awareness. At the age of 26 in April 1997, she fell in her bathroom. She tried to get up but ultimately fell again and lay there for three days–until a colleague noticed her absence from work and her father broke into her flat. Seventeen months in the hospital followed before she moved in with her parents. After years of suffering she was given a grant for a computer which allows her to communicate. She is now able to use the internet and to communicate with old friends and others who have locked-in syndrome. She also listens to music and audiobooks, is able to swallow melted chocolate and sometimes has occasional vodka via her feeding tube. She misses most the ability to talk and regrets being unable to eat burgers.
Tony Quan AKA Tempt One
Tony Quan, a popular graffiti artist, was diagnosed with the nerve disorder ALS in 2003 eventually leaving him fully paralyzed except for his eyes. Quan uses the technology called EyeWriter to communicate his art and has since had his work displayed in numerous art shows nationally.
In 1999, 16-year-old Erik Ramsey suffered a stroke after a car accident that left him in a locked-in state. His story was profiled in an edition of Esquire magazine in 2008. Erik is currently working with doctors to develop a new communication system that uses a computer that, through implants in his brain, reads the electronic signals produced when he thinks certain words and sounds. At present, Erik is only able to communicate short and basic sounds. However, doctors believe, within a few years, Erik will be able to use this system to communicate words and phrases, and eventually, to "talk" normally.
Tony Nicklinson, of Melksham, Wiltshire, England, was left paralysed after suffering a stroke in June 2005, at age 51. In the years that followed, he started a legal battle for a right to assisted death. On 16 August 2012, his request was turned down by the High Court of Justice. On learning the outcome of his appeal, he refused to eat, contracted pneumonia, deteriorated rapidly and died a week later on 22 August 2012, aged 58.
In 2010, ex-Premiership footballer Gary Parkinson suffered a massive stroke and was later diagnosed with locked-in syndrome. This, however, has not ended his career in football, as he is now part of Middlesbrough F.C.'s scouting analysis team, watching potential players on DVD and relaying the verdict to the Middlesbrough manager Tony Mowbray solely through blinking.
Lynsey Cribbin from Cavan, Ireland, woke up with several headaches in January 2012. She suffered multiple strokes which left her on life support and eventually with one of the most severe cases of locked-in syndrome. Her brain works but she cannot move.
In 2002, Elias Musiris made headlines as the first fully locked-in patient to regain some measure of communication through EEG. Though ALS had left Musiris unable even to move his eyes or blink, with training from neurological researcher Niels Birbaumer he learned to use an EEG brain-machine interface to answer yes-or-no questions and spell his name.
Stephen William Hawking has a motor neuron disease related to amyotrophic lateral sclerosis (ALS), a condition that has progressed over the years. He is almost entirely paralysed and communicates through a speech generating device. Since 2005, as disease progressed, he began to control his communication device with movements of his cheek muscles, with a rate of about one word per minute. Hawking is collaborating with researchers on systems that could translate Hawking's brain patterns or facial expressions into switch activations.
Cases in literature
The Count of Monte Cristo
The character M. Noirtier de Villefort in Alexandre Dumas's novel The Count of Monte Cristo apparently suffers from locked-in syndrome. He is described as a "corpse with living eyes", who communicates with eye movements and expressions. His grand-daughter Valentine helps him form sentences by reciting the alphabet and scanning dictionary pages with her finger until he indicates which letters and words he wants.
In Émile Zola's novel Thérèse Raquin, Thérèse Raquin and her second husband Laurent accidentally reveal to Thérèse's aunt, Madame Raquin (who has suffered from locked-in syndrome after a stroke), that they have killed Camille Raquin (Madame Raquin's son). One day, when some friends are over, Madame Raquin eventually musters an enormous amount of strength to move her finger on a table, tracing words that would reveal Thérèse's and Laurent's deed. However, she is interrupted, and her words are misinterpreted as "Thérèse and Laurent have taken good care of me".
The Ultimate Secret
The character of Jean-Louis Martin in Bernard Werber's SF novel L'Ultime secret, suffers from locked-in syndrome after being paralysed in a car accident. Able at first only communicate by blinking—once for "Yes" and twice for "No"—with the use of technology, he eventually gains control not only over his own mind, but that of others.
Sharon McCone, the protagonist of Marcia Muller's 2009 suspense novel Locked In is the founder of a successful San Francisco detective agency. Returning to her office late one night, she is shot in the head. She wakes up in a hospital able to move only her eyes, forced to struggle to rehabilitate herself while finding the attacker.
Johnny Got His Gun
Cases in popular culture
Alfred Hitchcock Presents
In the Alfred Hitchcock Presents episode titled "Breakdown", the sole survivor of a violent collision (Joseph Cotten) finds himself in a locked-in state, unable even to move an eyelid. The viewer experiences the victim's point-of-view, "hearing" his thoughts and feelings as they run from shock to anger to frustration to the realization that he may be put in his grave alive.
CSI: New York
The pilot of CSI: New York presented an instance of locked-in syndrome where a woman was sedated by the killer, who applied pressure to certain points on her head, resulting in her paralysis; the patient was portrayed by Jewel Christian. Previous attempts by the killer resulted in the deaths of his victims.
On an episode of Scrubs entitled "His Story III", a patient is presented with locked-in syndrome. The character is played by Henry LeBlanc.
In the television series Star Trek episode The Menagerie a Star Fleet captain (Christopher Pike, played by Jeffrey Hunter (healthy Captain Pike) and Sean Kenney (injured Captain Pike) ) is severely burned, completely paralyzed, and can communicate only by brain waves; he can operate an electrical wheelchair and can answer yes/no questions by "one flash for yes, two flashes for no". This episode aired in November of 1966; the first actual such interface was done by Fetz at the University of Washington in 1969 as noted in Brain–computer interface.
In the episode "The Uncanny Valley", the unsub Samantha Malcolm induces locked-in syndrome using a series of drugs in three women. Her reason is she is trying to complete a series of dolls she lost as a young girl. Every two months, a woman will die as the stress wreaks havoc on the body. Only one woman, who has diabetes, is able to counteract the drugs and fight off her locked-in syndrome.
Curare poisoning mimics a total locked-in syndrome by causing paralysis of all voluntarily controlled skeletal muscles. The respiratory muscles are also paralyzed, but the victim can be kept alive by artificial respiration, such as mouth-to-mouth resuscitation. In a study of 27 army volunteers who were paralyzed with curare, artificial respiration managed to keep an oxygen saturation of always above 85%, a level at which there is no evidence of altered state of consciousness. Spontaneous breathing is resumed after the end of the duration of action of curare, which is generally between 30 minutes and eight hours, depending on the variant of the toxin and dosage.
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- The Unlock Project
- Locked-in Syndrome Association's guide to communicating without language (French)[dead link]