Development of a music therapy assessment tool for patients in low awareness states

People in low awareness states following profound brain injury typically demonstrate subtle changes in functional behaviors which challenge the sensitivity of measurement tools. Failure to identify and measure changes in functioning can lead to misdiagnosis and withdrawal of treatment with this population. Thus, the development of tools which are sensitive to responsiveness is of central concern. As the auditory modality has been found to be particularly sensitive in identifying responses indicating awareness, a convincing case can be made for music therapy as a treatment medium. However, little has been recommended about protocols for intervention or tools for measuring patient responses within the music therapy setting. This paper presents the rationale for an assessment tool specifically designed to measure responses in the music therapy setting with patients who are diagnosed as minimally conscious or in a vegetative state. Developed over fourteen years as part of interdisciplinary assessment and treatment, the music therapy assessment tool for low awareness states (MATLAS) contains fourteen items which rate behavioral responses across a number of domains. The tool can provide important information for interdisciplinary assessment and treatment particularly in the auditory and communication domains. Recommendations are made for testing its reliability and validity through research.     

Musikalische Interventionen in der Psychodrama-Therapie

This article explains why music is an effective tool for the treatment of eating disorders and provides criteria for the choices of music. It summarizes the fundamental findings of music therapy research, the effect of music and the parallels from Moreno’s role levels to the musical components. To help psychodrama therapists with choices of tools, suitable instruments and types of music are discussed, and further literature sources provided. A case presentation illustrates the effect of music therapy interventions in psychodrama.     

Music therapy in oncology--concepts and review

The following article is addresses the applications and functions of music therapy in the acute and rehabilitative phases of treatment of adult cancer patients. It is based on a literature review with a focus on the state of empirical research in the oncology sector of music therapy and consequences for the concepts of music therapy. First the basic aspects of music therapy treatment are explained to clarify the different research methods and to examine the special demands of oncology patients. Furthermore, a brief summary of the approaches of music therapy research in the most renowned educational institutions in Germany are outlined. The results of the studies and case histories are summarized and evaluated and provide the basis for the conclusions and recommendations for the music therapeutic practice in oncology.     

Aggression in music therapy and its role in creativity with reference to personality disorder

This article describes a project that explored the relationship between aggression and creativity in music therapy. It examines the role of aggression in psychological growth and how music therapy might have a unique role in channelling aggression. An exploratory qualitative study included a mixed methods approach of a case study and thematic analysis of interviews. It included three interviews with three experienced music therapists who were asked about their experience of aggression in music therapy. The case study supports the evidence gathered in the interviews, and describes short-term individual music therapy treatment with a man with a personality disorder diagnosis and a history of extremely aggressive behaviour. The study suggested a strong link between aggression, affect and body movement. Gathered information and results from interview analysis showed that aggression and creativity share important similarities in areas of mastery and control, affect and emotion, and action and intention. Conclusions of the study showed that music therapy can sometimes provide a context for safe exploration of aggression and deeper feelings. It can also enable the individual to sublimate negative emotions through appropriate expression.     

Music Therapy Assessment Tool for Awareness in Disorders of Consciousness (MATADOC): Standardisation of the principal subscale to assess awareness in patients with disorders of consciousness

Establishing valid and reliable measures for use with patients with disorders of consciousness (DOC) following profound brain injury is challenging due to a number of factors including the complex presentation of such patients and assessor variability. The auditory modality has been demonstrated to have greater sensitivity for detecting awareness in DOC patients. However, there are no measures developed to assess auditory responsiveness specifically. The objective of this study was to examine the psychometric properties of the principal subscale of a music therapy assessment tool (MATADOC) developed for use with adult DOC patients. The subscale assesses behavioural domains essential for diagnosis of awareness. Twenty-one adult patients were recruited from a specialist rehabilitation unit. In a prospective study with repeated measures, internal consistency, inter-rater and test–retest reliability and dimensionality were examined. The five-item scale showed satisfactory internal reliability (α = .76) and a strong first principal component. Corrected item-total correlations were all > .45. Inter-rater intra-class correlations (ICCs) ranged from 0.65–1.00 and intra-rater ICCs from 0.77–0.90. Rasch analysis confirmed these impressions of a reliable, unidimensional and homogenous scale. Diagnostic outcomes had 100% agreement with a validated external reference standard. The results indicate that the MATADOC principal subscale provides a new behavioural measure that can contribute to interdisciplinary assessment of awareness with DOC patients.     

Psychological needs of patients in low awareness states, their families, and health professionals

Patients who have emerged from low awareness states may present with psychological needs that can be addressed via adapted formal clinical psychological interventions, or by behavioural techniques. Families of these patients may experience similar psychological reactions to relatives of any patients with severe brain injury, but there are also additional factors that are unique to patients in low awareness states. These sources of psychological distress for relatives are discussed. The needs of clinicians working with these clients are also discussed. It is important that services attending to the needs of clients in low awareness states also have adequate support for both relatives and clinicians.     

Vegetative and minimally conscious states: serial assessment approaches in diagnosis and management

Assessment of vegetative (VS) and minimally conscious state (MCS) patients presents clinicians with inherent difficulties (Royal College of Physicians, 2003) in terms of the reliable detection of potential signs of awareness given that all current assessment tools rely on observed behaviour. Recently developed measures such as SMART (Gill-Thwaites & Munday, 1999) and WHIM (Shiel et al., 2000), employing structured operational defined behavioural observations can facilitate the serial assessment of patient awareness, progress and appropriate goal setting particularly as one-off bedside assessments are more likely to be inaccurate. The use of sensitive tailored approaches involving experienced multidisciplinary teams is strongly advocated (Royal College of Physicians and British Society of Rehabilitation Medicine, 2003), notwithstanding clinicians should carefully consider potential confounding clinical factors, which may deleteriously influence patient arousal or ability to respond. Finally, areas for future development and recommendations regarding multidisciplinary assessment approaches with VS and MCS patients are outlined.     

Effects of music therapy on spirituality with patients on a medical oncology/hematology unit: A mixed-methods approach

Despite considerable interest in the potential relationship between oncology and spirituality, it remains unclear how the spiritual wellbeing of patients is best addressed in health care environments. The purpose of this study was to determine the effect of three music therapy doses on spirituality in patients on a medical oncology/hematology unit (N = 17). The researchers measured participants’ faith, peace, and meaning by using the FACIT-Sp. tool ( Brady, Peterman, Fitchett, Mo, & Cella, 1999) at pre- and posttest during a randomized controlled design. The researchers also incorporated interviews from patients concerning potential effects of music therapy and spirituality. Quantitative results indicated significant between-group differences in peace and faith subscales, with participants in the music therapy condition having higher posttest means than participants in the control condition. Qualitative data tended to support the importance of music therapy in meeting spiritual needs: Results of a thematic analysis indicated music therapy helped participants feel closer to God and elevated their moods. Consistent with the literature base, participants noted that that spiritual needs should indeed be addressed during a person's time at the hospital. Limitations of the study, areas for future investigation, and implications for clinical practice are provided.     

Responses of Patients with Disorders of Consciousness to Habit Stimulation: A Quantitative EEG Study

Whether habit stimulation is effective in DOC patient arousal has not been reported. In this paper, we analyzed the responses of DOC patients to habit stimulation. Nineteen DOC patients with alcohol consumption or smoking habits were recruited and 64-channel EEG signals were acquired both at the resting state and at three stimulation states. Wavelet transformation and nonlinear dynamics were used to extract the features of EEG signals and four brain lobes were selected to investigate the degree of EEG response to habit stimulation. Results showed that the highest degree of EEG response was from the call-name stimulation, followed by habit and music stimulations. Significant differences in EEG wavelet energy and response coefficient were found both between habit and music stimulation, and between habit and call-name stimulation. These findings prove that habit stimulation induces relatively more intense EEG responses in DOC patients than music stimulation, suggesting that it may be a relevant additional method for eliciting patient arousal.     

Considerations for the use of assistive technology in patients with impaired states of consciousness

While there is limited literature addressing the application of assistive technology in patients in persistent vegetative state (PVS) and minimally conscious state (MCS), it is believed that it can assist with the assessment, diagnosis and treatment as well as management of these patients. The use of technology to assist in PVS and MCS is mostly limited to the application of simple binary switch devices to determine whether a motor response is consistent or otherwise. However, the application of such technology is often undermined due to a lack of established protocols for use by the multidisciplinary team (MDT), as well as a lack of available technical resources. Therefore the ongoing development of assessment instruments as well as effective outcome measures used by an MDT is imperative. This article aims to discuss some key aspects to consider in the use of assistive technology when assessing and treating people in impaired conscious states. Possible considerations and suggestions will be discussed through this paper and a case study will be used to demonstrate some of these interventions.     

Music therapy in the treatment of multiple sclerosis: a comprehensive literature review

Coping with multiple sclerosis symptoms still remains a challenge for each patient suffering from this chronic inflammatory disease. Therefore, patients often turn to using complementary and alternative medicine (CAM). In this review, the authors aimed to investigate the current state of literature of music therapy in the treatment of multiple sclerosis (MS). Medline, PubMed, Embase, AMED, CAMbase and the Music Therapy World Journal Index were searched for the terms MS and 'music therapy'. In addition, an internet search using Google Scholar was performed. The authors found seven case-reports/series and seven studies on music therapy for MS-patients. Both the case reports and studies presented here are pioneer work. Most of the studies are naturally predominated by the use of qualitative and uncontrolled research designs. Nevertheless, the results of the studies as well as the case reports demonstrate patients' improvement in the domains of self-acceptance, anxiety and depression. The results of the studies as well as the case reports define a sufficient basis for further music therapeutical work as they show a variety of psychosocial and emotional benefits for MS patients.     

Impairment of autonoetic awareness for emotional events in schizophrenia.

OBJECTIVE: To investigate the subjective states of awareness accompanying recognition of emotional events in patients with schizophrenia. METHOD: During the learning phase, a set of neutral pictures associated with emotional sentences was presented to 24 patients with schizophrenia and 24 healthy control subjects. During the test phase, participants had to recognize target pictures and valence and to report their subjective state of awareness (Remember, Know, or Guess) associated with recognition of pictures and valence. RESULTS: Patients with schizophrenia exhibited poor recognition of pictures and emotional valence. The frequency of Remember responses associated with recognition of pictures and of valence was lower in patients than in control subjects. CONCLUSIONS: Autonoetic awareness for emotional events is reduced in schizophrenia, with patients presenting difficulties in consciously recollecting the specific details that make events emotional.     

The neurological assessment of patients in vegetative and minimally conscious states

Patients with serious central nervous system (CNS) injuries can enter a chronic state in which there is impaired awareness, but the presence of preserved basic vegetative functions. Such cases present formidable challenges to the medical practitioner in terms of clinical assessment and thus management. This paper presents the neurological approach to such patients highlighting the clinical clues that need to be sought to decide whether the patient is in a persistent vegetative or minimally conscious state (i.e., showing any responsiveness to external stimuli), or alternatively suffering from a locked-in syndrome. This neurological clinical formulation is then assimilated with other tests and assessments from a range of medical specialities, and by so doing helps confirm the clinical impression. This multidisciplinary approach is vital in the assessment of such patients and ideally should also include neurophysiological and functional imaging paradigms.     

Persistent vegetative state and dementia in the elderly

BACKGROUND: Very few studies have approached the issue of persistent vegetative state (PVS) within the elderly population. This study aims to assess the prevalence, determinants and prognosis of elderly patients with PVS admitted to a long-term geriatric facility. METHODS: We conducted a cohort study in the setting of a Skilled Geriatric Nursing Department. All patients admitted during a 17-month period (N = 88) were included and tested for a diagnosis of PVS according to the Disability Rating Scale (DRS). RESULTS: A clinical diagnosis of PVS was given to 15% of patients upon admission, whereas the DRS diagnosed 30.5% of patients as having PVS. During the study period, 12 out of 31 patients with PVS died, with a median survival of 127 days (range: 1-517 days). CONCLUSION: Our study suggests that PVS is an advanced stage in the natural history of dementia in the elderly. The low proportion of patients with PVS recognized as having this disorder upon admission suggests a low awareness among hospital personnel. Further studies of the prevalence and determinants of PVS in the severely disabled elderly population are warranted.     

Effects of music therapy on positive and negative affect and pain with hospitalized patients recovering from a blood and marrow transplant: A randomized effectiveness study

Due to the extensive procedures surrounding treatment, cancer patients often experience a variety of physical and psychological symptoms and side effects that negatively impact their quality of life and ability to cope with and manage an illness. Providing a choice of music during a receptive music therapy session may not only distract the patient from negative affective states, but also may provide a sense of autonomy and control over a patient's immediate environment. The purpose of the study was to determine whether receptive music therapy can improve two general dimensions of emotional experience and pain in a single session for hospitalized patients recovering from a blood and marrow transplantation (BMT) procedure. The guiding research question was: Will participants experience improved positive and negative affect and pain immediately following a patient-preferred live music therapy session? Participants (N = 32) were randomly assigned to experimental or wait-list control conditions and completed the Positive and Negative Affect Schedule (Watson, Clark, & Tellegen, 1988) Short Form version and a Likert-type Pain Scale as a pre- and posttest within a single-session design. In an attempt to provide support, autonomy, and distraction, patient-preferred live music was used in receptive music therapy sessions as previous music therapy researchers indicated patient-selected live music is preferred and can be effective. There were no between-group differences at pretest. Concerning posttest analyses, there were significant between-group differences in positive and negative affect and pain, with experimental participants having more favorable scores than control participants. From the results of this randomized effectiveness study, it seems that a single receptive music therapy session can be an effective intervention concerning positive and negative affect and pain for hospitalized BMT patients. As higher levels of patient engagement may result in stronger treatment effects, future research encouraging hospitalized BMT patients to engage in different types of active music therapy interventions is warranted. Limitations of the study, implications for clinical practice, and suggestions for future research are provided.     

Music therapy techniques as predictors of change in mental health care

The application of music in therapy is realised through different working modalities which can be categorised into three types of techniques: production, reception, and reproduction. These techniques are commonly used in mental health settings in music therapy practice and previous research suggests that specific working modalities might be important predictors of change in music therapy. However, little is known about which ingredients specifically contribute to the outcomes of music therapy. This study aimed to investigate the application of music therapy techniques and whether they predict changes in clinical outcomes in mental health settings with individuals displaying a low therapy motivation. Participants (N = 31) were assessed before, during, and after participating in individual music therapy. Music therapy techniques were assessed for three selected therapy sessions per participant. Associations between music therapy techniques and outcomes were calculated using linear models with repeated measures. Results showed that reproduction techniques were used most intensely. In addition, relational competencies (interpersonal and social skills) amongst the participants improved when focusing on reproducing music (e.g. singing or playing familiar songs, learning musical skills). Results indicated that reproduction music therapy techniques may foster the development of relational competencies in individuals with low motivation.     

Music therapy in children's hospices: An evaluative survey of provision

This paper presents the results of a survey of the range of music therapy practice in children's hospices in the UK. Music therapists are challenged to work with children with life-limiting and life-threatening conditions during short periods of respite care over several years or at end of life. Flexibility is fundamental to working both individually and in small groups in response to the shifting needs of the children and their families. In the context of a children's hospice music therapists are called upon to work creatively with siblings and family members and members of the multidisciplinary team in addition to the children themselves. A questionnaire and focus group for music therapists working in the children's hospices provided evidence of the range of work, priorities and future plans for development. Telephone interviews with specialist staff at children's hospices where music therapists were not currently working provided evidence of how music and musical activities were perceived and utilised, with any plans for future provision for a music therapy service and some of the practical and resource issues being itemised.     

The prognostic value of noninvasive CBF measurement in subarachnoid hemorrhage

Seventy-four measurements of cerebral blood flow (CBF) were performed using the Xenon 133 inhalation method in 50 cases of spontaneous subarachnoid hemorrhage. This method is non-traumatic, reproducible and dependable. A correlation was found between clinical condition and CBF values, but in a number of cases which cannot be dismissed, very low mean CBF values or ischemic foci were revealed where clinical state gave no indication of same. A poor correlation appeared between vasospasm seen by angiography and ischemic foci detected by isotopic technique. Patients' age influenced CBF values but not clinical evolution. CBF values, measured in the first two weeks of illness, were significantly higher in those patients having favorable outcome, whatever their clinical state at the time of CBF measurement (comas excluded). The figure of 60 ml/100g/min. for mean cortical flow seemed to be a critical level below which risk of complications was greater. Conversely, in every case where mean cortical flow measured above 70 ml, outcome was favorable. Thus, CBF measurement promises to be a valuable prognostic tool, playing an important role in the therapeutic strategy for this type of patient.     

The application of transcranial magnetic stimulation in psychiatry and neurosciences research

OBJECTIVE: Over recent years transcranial magnetic stimulation (TMS) has become widely applied in the study of neuropsychiatric disorders. The aim of this article is to review the application of TMS as an investigative tool and as a potential therapeutic modality in psychiatric disorders. METHOD: A comprehensive literature review. RESULTS: When applied as an investigative tool, TMS provides innovative ways to directly study the excitability of the cortex, cortical regional connectivity, the plasticity of brain responses and cognitive functioning in illness and disease states. A number of studies suggest the potential of treatment with TMS in disease states, especially in patients with depression, although difficulties exist with the interpretation of the published literature. CONCLUSION: TMS has a considerable role in neuropsychiatric research. It appears to have considerable potential as a therapeutic tool in depression, and perhaps a role in several other disorders, although widespread application requires larger trials and establishment of sustained response.