Column April 2005 of Gillian Hotz, PhD Director Neurotrauma University of Miami (English)

Written by Gillian Hotz
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The Effects of Snoezelen Therapy in Children with Traumatic Brain Injury



Over the past two years we have been able to implement and develop a Snoezelen Program in a Pediatric Rehabilitation Unit at the University of Miami School of Medicine/ Jackson Memorial Medical Center .

With such a large number of children admitted to our hospital with severe and moderate traumatic brain injury (TBI) we were looking for an adjunct to standard therapies (physical, occupational and speech) received in a comprehensive neurorehabilitation program, that would increase awareness and improve function for those in minimally conscious states and decrease agitation for those in confused/agitated states.

From numerous anecdotal reports and few randomized controlled trials it appears that Snoezelen therapy may be worth investigating in this patient population.



As stated by many, Snoezelen has been developed based on systematic observations and not on theoretical and evidenced based research. We thought that there was an opportunity to conduct empirical testing and scientific investigations. Due to the nature of TBI and natural history that children progress through in recovering from severe brain injury, controlled multi-sensory therapy may be beneficial to assist those emerging from coma or minimally conscious states. Early traditional treatment for this group of patients includes coma stimulation or sensory regulation programs. Snoezelen, a controlled multi-sensory stimulation therapy may be a novel approach for treating children recovering from brain injury. Animal and human studies have reported changes in behavior in enriched environments.


The rationale that supports the benefits of treatment in snoezelen or a controlled multi-sensory stimulating environment includes the effects that plasticity and developmental factors may have on a young injured brain. Recovery from pediatric brain injury entails a complex interplay among diverse factors, such as the pathophysiology of the brain injury, the developmental stage at the time of injury, cerebral plasticity, the amount of time after the injury, and the child\'s reserve of psychosocial resources.

Investigators have found that some impairments in young children actually increase in severity over time after injury. Early insults may limit the brain\'s capacity to develop normally or may interfere with the timing of neural development. In addition, new deficits may emerge at later stages after injury. Psychosocial resources include the child\'s pre-morbid potential for new skills acquisition, support of family, school, peers, and the availability of effective rehabilitation programs.

Other experts argue that the concept of cerebral plasticity of the developing brain still seems to lead to more favorable outcomes after TBI for younger age groups. The use of the environment to enhance plasticity and improve neurological function has been extensively studied in animal injury models. Together with plasticity, new connections and environmental stimulation can be used in an intervention to improve cognitive function and produce behavioral changes in humans.





The multi-stimulation approach demonstrated in a Coma Recovery Program or Coma Arousal Therapy is based on behaviorism with the belief that intensive stimulation provided to all senses will enhance synaptic reinervation and stimulate the reticular activating system to increase brain synapses and function.

The rationale is that exposure to frequent and various sensory stimulation will facilitate both dendritic growth and improve synaptic connectivity in those with damaged nervous system. Most sensory stimulation programs are designed to prevent sensory deprivation and to provide structured input in order to maximize a patient's ability to process and respond to stimuli.

The ultimate goal of enriched environments is to facilitate recovery of the nervous system so that patients are able to process information of increasing variety and complexity. From review of snoezelen literature, the basic philosophy and theories seemed to meet our needs for an alternative treatment that would be beneficial for children recovering from severe TBI.



However, prior to initiating our clinical research study we first had to be trained, set up a Snoezelen room and become familiar with Snoezelen therapy techniques. We also had to trial different physiological and behavioral outcome measures and decide which ones would be appropriate to measure change.

The training was provided by Michelle Shapiro and Mona Julius, Snoezelen experts from the Beit Issie Shapiro Center in Raanana Israel . They came to Miami and provided a certified training course to our therapists and helped to set up our Snoezelen room. They were able to demonstrate techniques working with children with TBI in the room.




The purpose of our study was to prospectively study 15 children recovering from severe brain injury by measuring physiological, cognitive and behavioral changes pre and post Snoezelen treatment sessions. Results revealed significant changes on physiological measures.

Heart rates (HR) decreased for each subject in each treatment session and were found to be significant. Muscle tone was decreased in the affected extremity (right-upper extremity, and left-lower extremity. Agitation levels decreased over time and cognitive outcome measures showed significant improvement.

We were encouraged from these initial findings to further investigate the effects of Snoezelen therapy in children recovering from severe brain injury. We would like to either find or develop better outcome measures, compare Snoezelen therapy to traditional therapies and investigate neuroimaging techniques.

For further explanation of our findings, we have submitted the article for publication. At this point we welcome any suggestions, recommendations or feedback from our worldwide colleagues.



Gillian Hotz, PhD


  • Director Neurotrauma Outcome Research
  • Co-Director Pediatric Brain Injury Program
  • Associate Research Professor
  • Division of Trauma and Surgical Critical Care
  • DeWitt Daughtry Family Department of Surgery
  • University of Miami , Miller School of Medicine
  • Email: This email address is being protected from spambots. You need JavaScript enabled to view it.

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