Using Azam software for the stimulation, rehabilitation and arousal of coma and brain injured patients

This page contains a general overview for use by members of the public and is not just for medical staff.

Under the Azam Disabilities Initiative (ADI) hospital intensive care wards qualify for free use of Azam software in the treatment of brain injured or comatose patients. Family members of the patient may also download Azam free of charge for this purpose but are advised to seek medical supervision as described within this article. Hospitals should email adi@azamit.com to request free software keys. To save on administration, family members are advised to download Azam and create the recordings they wish to use within the 30 day free trial period. This can be extended indefinitely by sending a request to the above email address.

Important note

The subject of audio stimulation for coma therapy is controversial. Some doctors believe it helps, others believe it neither helps nor does any harm and the patient will wake up when they are ready. What will be described below is not some new miracle cure. We do not want to raise the hopes of families who are already under considerable distress. We do not recommend any medical procedure be undertaken without medical advice and supervision. Our audio stimulation delivery method cannot help certain comatose conditions, such as after brain surgery or while other physical problems or conditions prevail.

A brief synopsis relating to coma and how Azam software could help, will now be described.

Coma is: " ... the total absence of awareness of self and environment even when the subject is externally stimulated."

There have been many studies undertaken relating to coma recovery. Head injury is a major cause of death and permanent disability. In New South Wales, a report from the Government Insurance office indicated that road trauma accounts for 70 percent of cases of severe brain damage and that 50 percent of these occur in the 17 to 25 year age group. The report further indicates that approximately 1,000 people each year are left with a permanent deficit in brain function and that one third will be left seriously disabled for life. These people are often forgotten, seen as being beyond the help of rehabilitative care. However Ian Hunter, in an oral submission to the Parliamentary Social Development Committee inquiry into the options for dying with dignity stated: It cannot be proven that there is no potential for recovery following brain injury, even in the most severe cases, because there is no known diagnostic test that can scientifically demonstrate that recovery of function will not occur (therefore) every attempt should be made to tap this.

Through controversial coma arousal programmes it is being shown that even when in a coma a person may be reached through the use of external stimulation. Coma arousal is a planned series of activities aimed at "arousing" a person from a coma.

Coma arousal therapy

The basis of coma arousal therapy lies in the frequency, intensity and duration of environmental stimuli that the patient receives. Stimuli may be via the five sensory modalities (vision, hearing, touch, taste and smell) by which the brain receives information about the outside world and physical movement. Sensory stimuli are essential factors in stimulating the reticular activating system (consciousness control centre) to maintain consciousness.

Basically, any comatose patient in a stable medical condition is a suitable subject for a coma arousal programme. Coma mostly results from head trauma sustained in motor vehicle accidents and it is this category of patient most commonly found in coma arousal programmes. Patient assessment is essential prior to commencement of the programme. Dr Freeman (who undertook a coma arousal feasibility study at the Sydney College of Advanced Education) points out that though it is relatively easy to assess the physiological state, it is difficult to measure the degree of brain function. He believes that the Glasgow Coma Scale (GCS) enables a uniform approach to assessing severe brain injury but questions its value once the patient is scoring above 9; a score of 8 or less out of a total of 15 is usually considered to indicate coma. Due to possible GCS inaccuracy on scores of 9 or above, Freeman suggests that assessment of brain function should involve determining the patient's visual, auditory and tactile abilities on a continual basis.

Coma arousal therapy should commence as soon as possible after the development of coma and may start in the intensive care unit providing the person's medical condition is stable. Coma arousal programmes are very labour intensive and it has been suggested that the best therapists are those who are interested and caring - frequently relatives or significant others. In addition, those closest to the person are more likely to receive and see a response. As Freeman notes: "Often the relatives have indicated to us that the patient has an awareness which is much greater than we can detect. We listen carefully, because we find them to be right so often."

Some studies have shown stimulation programmes using music can arouse coma patients and provide examples of other stimulation programmes used in the past. The use of music in rehabilitation and the goals of music therapy are described by some doctors. Also studied are the reasons for using music as a stimulus, what kind of music and how it should be presented, and what kinds of non-musical stimuli you would want to include in the rehabilitation programme. One team has produced a video which also stresses the importance of conversation with the patient and the pairing of touch with the music during therapy, and family involvement. It includes charting examples, examples of responses, examples of musical stimuli, and examples for non-musical stimuli. Recent studies of the use of music therapy with coma patients are mentioned. (Please refer to the links below).

Here is a quote from a patient's daughter, Andrea "My father whom I love dearly suffered a cardiac arrest. It's been 1 1/2 years. I spend 6 hrs everyday with him. I do a lot of coma stimulation techniques. He smiles at me, when I ask sometimes or if I show him how, it's like he'll mimic me. I don't know though if he knows I am his daughter for 37 yrs." However research shows us that it doesn't take a miracle for patients to come out of a coma and do well.

The section above was prepared by obtaining information from the following websites:

Using Azam software for the task: Overview

Azam software can easily be used to record some of these stimulation techniques of musical and non-musical stimuli and repeatedly play them back to the patient. Azam can be used to mix the musical and non-musical messages. As stated in some of the recovery techniques it is often better to have several different types of messages and recordings. For example loud, soft, high pitch and in some cases slowed down or even speeded up.

This can be done using Azam voice filter functionality. Azam software is built with a set of unique morphing functions that far exceed the limits of most recording devices. Friends and relatives who know the patient's tastes can even monitor the patient's awareness, can create customized voice recordings and musical excerpts using Azam. These 'sound clips' can be filtered and recorded to perfection as a very simple exercise. As an example, let's assume one of the voice clips was emailed from the patient's grandmother. Using Azam, an ordinary 5 minute audio track could be produced, copied, morphed and merged into the final CD. Grandma's voice could then be heard normally, fast, slow, and/or with the other morphing effects such as with an echo or even backwards. By doing this, it could light a spark in the deepest subconscious of the patient. Please refer to the voice audio clip example we have produced on our website which can be played on most PCs that have MP3 or Wav capability.

We wish to emphasize that there is nothing stopping a family from producing a simple tape recording in a short space of time, using an ordinary tape recorder, nevertheless, it can be very cumbersome to collect and merge audio clips from several sources, some of whom may live some distance away from the hospital or the physical recording machine. Additionally, very few recording devices have the morphing capability of Azam software. Azam even allows voice clips to be recorded during a preplanned phone conversation directly onto a PC. Patients who are in a coma, brain injured, traumatized or unconscious can be given various forms of audio stimulation to help bring them out of their state. We are here to provide some innovative, state of the art technology that may assist. View specific screen shots

Diagram of voice and audio clips collected from different sources, emailed to a central Azam enabled PC that will create an MP3 CD to play back to the patient.

Using Azam software for the task: Specific guidelines and suggestions

Identify a PC proficient family member or a friend who will volunteer to be the coordinator. At present Azam is only available in English.
This individual should download Azam onto any compatible PC that has at least 100 Meg of free disk space and CD burner software.
Using Azam, record a series of voice messages for the patient. A selection of the above audio clips can be morphed in addition to normal playback. The message could be a short or long reading from the patient's favorite book. You could record several messages for example from the patient's close family, best friends or even celebrities. These recordings can be created anywhere in the world and emailed to the coordinator. Azam will need to be downloaded onto other PCs, by participants who do not have access to Azam. (In the event that some participants do not have easy access to a PC, a tape recording message can be posted to the coordinator who will convert them into Azam recordings). Several such voice messages, reading recitals and music can then be merged using the Azam Studio Mixing function into one simple recording and a CD burned and played via an MP3 player to the patient.
Each audio clip should last 3-7 minutes and be pre-planned and rehearsed.
Each audio clip should contain reminders of recent and distant events in the life of the patient.
When the final customized recording has been produced, Azam can convert the finished product into MP3 format (by cutting a CD) which can be played to the patient using a portable player and earphones.
Some audio clips should be emotional but most should not.
Subject to medical advice, it is recommended at least one hour of recordings are merged into one, using the above techniques.(Do not exceed 77 mins).
There is nothing stopping the same message being repeated several times to fill the CD, which will allow playback to continue for hours on end. Nevertheless expert medical advice should be sought as some research has pointed out dangers of coma patients being given the same stimulus.
Morphed recordings should not be played back to back, but interspersed with normal voice clips. At most, only 1 in 7 recordings should be played backwards.
Burn at least 2 master CDs for hospital use and keep a master CD at home.
The coordinator should create a version 1 of the CD using basic Azam functionality as soon as possible for the patient's use. A more complicated version using all available Azam functionality such as morphing can be produced later.

Azam's extensive online help screens and printable "Getting Started Manual" provide a wealth of technical information to undertake the above. View specific screen shots

Suggested scripts:

Imagine the patient is at home and you are trying to wake them up from a deep sleep.
Imagine you are reading a letter you have just written to the patient about events he or she is interested in relating to friends, family, school and sports.
Start each audio clip with "Dear/Hello ______. This is ________ and I have a special message for you while you are asleep at _________ hospital.
Remind the patient of favorite memories (holidays, sports events).
How their favorite sports team is doing.
If a reading from a holy book is chosen, it should be a positive section that is easily understandable. View examples.
End each audio clip with "I would like you to wake up now".
Only a few audio clips should contain assertive communications. Only perceived authority figures such as a teacher or parent should record in this way, but always end the audio clip in a non-assertive/aggressive way.

The recordings you will create as a family will probably contain memories that are very private and personal relating to the patient's life. It may even be improper to divulge such close family matters to certain participants of the final CD such as friends, teachers or workmates. Please respect the privacy of everyone concerned. If all goes well and a full recovery ensues, let the patient decide whether to allow external parties access to these special messages.

Example of a finished CD using basic Azam functionality (i.e. no morphing)

Track 1	All merged audio voice clips from family and friends.
Track 2	(Optional) uplifting poem or music track.

We have included a thought provoking poem relating to World Peace on this website for download, which can be used by anyone (religious, spiritual or atheist). Juan Carlos Calderon, the Spanish composer who has written songs for Ricky Martin, Louis Miguel and others, has very kindly agreed to allow the use of the music to his hit beautiful number one song 'Amarte es un placer' for use in the Azam coma initiative. The lyrics to 'The Ancient Song of the Human Race' were written by Andronicos as part of one of his other projects. It has been included here because it is not often easy to get legal copies of downloadable music from the internet. Download and play for coma patient use (WMA format). Alternative MP3 format. If the patient is religious, refer to track 7 below.

Example of a finished CD using all available Azam functionality

The maximum time should not exceed the capacity of 1 CD (approx 77 mins).

Track 1	Normal audio voice clips from four merged Azam recordings (closest family members).
Track 2	Favorite song (Ballad)
Track 3	Normal audio voice clips from four more merged Azam recordings (other family members).
Track 4	Favorite song (fast/loud)
Track 5	Remaining audio voice clips which have been merged into one Azam recording (friends etc).
Track 6	Morphed audio voice clips from 1 or 2 close family members.
Track 7	Rendition from uplifting non-religious book, poem, and/or a holy book of the patient's religious beliefs. View a list of specific readings, based on different religious Faiths. (A section for those not particularly religious is also included.)

View specific screen shots

Using Azam software after the patient has recovered

Following recovery to full consciousness, some patients have short or medium term memory loss. Consider using Azam software to facilitate voice emails from friends and relatives who need to remind the patient of forgotten memories. Even face to face discussions and phone calls can be recorded using Azam so the patient can analyze what was said afterwards and hopefully prompt in the restoration of forgotten memories.

For Doctors and Nursing Staff

A form has been produced offering suggestions and to enable the study to take place. Please download the 2 page PDF from here.

Conclusion and disclaimers

Kindly note this whole section was written by Andronicos, inventor of Azam and Head of the Azam Disabilities Initiative. He is not a doctor. He would be very grateful for feedback, suggestions and results because it is imperative we know how you get on using Azam in this way so that other patients in similar positions can be helped. Please email coma@azamit.com. This is a high priority email address only for use by medical professionals.

A couple of disclaimers follow: This is a live research project, which should only be attempted with the approval of a doctor. Strictly speaking, copying copyright music for use in the manner described above should be with the permission of the record company concerned. Azam Version 2 is required for voice morphing.

As described at the start of this page, under the Azam Disabilities Initiative (ADI) hospital intensive care wards qualify for free use of Azam software in the treatment of brain injured or comatose patients. Family members of the patient may also download a copy of Azam free of charge for this purpose but are advised to seek medical supervision as described within this article. Hospitals should email adi@azamit.com to request free software keys. To save on administration, family members are advised to download Azam and create the recordings they wish to use within the 30 day free trial period. This can be extended indefinitely by sending a request to the above email address. If you wish to use Azam in this way, please email adi@azamit.com and let us know how you get on.

Finally, if you are reading this section because a friend or relative is in a coma or is suffering from a brain injury, we recognize this must be a very difficult time for all concerned. The whole Azam team wishes the patient all the best for a speedy recovery.

Read the executive one page summary (for Consultants, Surgeons and Senior Nursing Staff)