Wendy L. Magee

Neurophysiological and behavioral responses to music therapy in vegetative and minimally conscious States.

Assessment of awareness for those with disorders of consciousness is a challenging undertaking, due to the complex presentation of the population. Debate surrounds whether behavioral assessments provide greatest accuracy in diagnosis compared to neuro-imaging methods, and despite developments in both, misdiagnosis rates remain high. Music therapy may be effective in the assessment and rehabilitation with this population due to effects of musical stimuli on arousal, attention, and emotion, irrespective of verbal or motor deficits. However, an evidence base is lacking as to which procedures are most effective. To address this, a neurophysiological and behavioral study was undertaken comparing electroencephalogram (EEG), heart rate variability, respiration, and behavioral responses of 20 healthy subjects with 21 individuals in vegetative or minimally conscious states (VS or MCS). Subjects were presented with live preferred music and improvised music entrained to respiration (procedures typically used in music therapy), recordings of disliked music, white noise, and silence. ANOVA tests indicated a range of significant responses (p ≤ 0.05) across healthy subjects corresponding to arousal and attention in response to preferred music including concurrent increases in respiration rate with globally enhanced EEG power spectra responses (p = 0.05–0.0001) across frequency bandwidths. Whilst physiological responses were heterogeneous across patient cohorts, significant post hoc EEG amplitude increases for stimuli associated with preferred music were found for frontal midline theta in six VS and four MCS subjects, and frontal alpha in three VS and four MCS subjects (p = 0.05–0.0001). Furthermore, behavioral data showed a significantly increased blink rate for preferred music (p = 0.029) within the VS cohort. Two VS cases are presented with concurrent changes (p ≤ 0.05) across measures indicative of discriminatory responses to both music therapy procedures. A third MCS case study is presented highlighting how more sensitive selective attention may distinguish MCS from VS. The findings suggest that further investigation is warranted to explore the use of music therapy for prognostic indicators, and its potential to support neuroplasticity in rehabilitation programs.

Brain-Computer Music Interfacing (BCMI): From Basic Research to the Real World of Special Needs

This paper reports on the development of a proof-of-concept brain-computer music interfacing system (BCMI), which we built to be tested with a patient with Locked-in Syndrome at the Royal Hospital for Neuro-disability, in London. The system uses the Steady State Visual Evoked Potential (SSVEP) method, whereby targets are presented to a user on a computer monitor representing actions available to perform with the system. Each target is encoded by a flashing visual pattern reversing at a unique frequency. In order to make a selection, the user must direct her gaze at the target corresponding to the action she would like to perform. The patient grasped the concept quickly and rapidly demonstrated her skill at controlling the system with minimal practice. She was able to vary the intensity of her gaze, thus changing the amplitude of her EEG and vary the consequent musical parameters. We have proved the concept that such a BCMI system is cost-effective to build, viable, and useful. However, ergonomic and design aspects of the system require further refinement in order to make it more practical for clinical usage. For instance, the system at present requires a therapist to place individual electrodes and calibrate a user’s response to each stimulus, which can be time consuming. A new version of the system will require just positioning of a headset and, due to advanced algorithms, will require no calibration.

An Exploratory Study of the Use of Electronic Music Technologies in Clinical Music Therapy

In line with wider health and educational services, there is a growing demand for music therapists to apply electronic music technologies in clinical practice. Despite a handful of accounts indicating the benefits these tools offer, an objective assessment of their role in music therapy and guidelines for their application in therapy are lacking. A qualitative study collected data in semi–structured individual interviews from music therapists experienced in using electronic equipment using MIDI generated sounds triggered by specialist input devices. Interview transcripts were analyzed independently by two multidisciplinary investigators using open coding procedures from Grounded Theory, with member checking to enhance credibility. The findings propose a five–step treatment model when using technologies with people with complex needs. Accurate assessment of movement, positioning of the technology, and establishing the clients awareness of cause and effect are central to meeting clinical aims. Clinical indicators include complex physical and sensory disabilities, motivational problems, and specific needs pertaining to expression of identity. Their use is contraindicated in cases where it is known the client has no awareness of cause and effect.

Music as a diagnostic tool in low awareness states: considering limbic responses.

Primary objective: Examining the evidence from contrasting epistemological sources a case is made for the use of music as an assessment medium with patients in low awareness states. Profound brain damage can result in long-term states of altered consciousness such as vegetative and minimally conscious states. Differential diagnosis with this population is immensely complex requiring diverse approaches. Neuroimaging alone is not, as yet, sufficient to establish diagnosis in this population and must be supplemented by repeated behavioural observation methods from a skilled and diverse treatment team, as there are enormous medico-legal and ethical implications. Evidence from research in neuroimaging and the behavioural health sciences indicates that auditory stimulation can reveal residual functioning and elicit optimal behaviours in such patients, particularly when the stimulation has emotional significance. Main outcomes and results: Behavioural assessment is complicated by limbic behaviours which can be misinterpreted as purposeful emotional responses. A case vignette using music therapy in a complex case illustrates such complications. Conclusions: Given the evidence for residual auditory functioning in patients in low awareness states, music is recommended as a medium for assessment. However, professionals involved in diagnosis must take caution against misinterpreting limbic responses and attributing greater meaning to such behaviours.

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.

Singing in therapy : monitoring disease process in chronic degenerative illness

Music therapy in the treatment of chronic neurological illness typically focuses on the use of music to address the emotional and psychosocial impact of loss and change stemming from pathology. A range of clinical techniques is described in anecdotal accounts spanning instrumental improvisation, song composition and singing. However, there is scant reference to the musical and emotional experience of singing as a clinical technique with individuals living with chronic degenerative illness. Drawing on the results of an empirical investigation into the effects of music therapy with clients with chronic neurological illness, this paper reveals how singing may be used by clients to monitor their physical disease process. Grounded theory research with this population has revealed that music therapy elicits processes in which individuals monitor the physical changes caused by their disease process (Magee and Davidson 2004). Based upon these research findings, this paper illustrates that individuals living with illnesses which cause loss of voice function may find the act of singing a highly physical experience. As such, singing may be used to monitor subtle changes which have occurred due to the disease process. Individuals living with degenerative illness may use singing within therapy as a way to defy their illness process and as an expression of lifes breath running through the body. Singing and voice work within clinical music therapy is therefore not only a vehicle for emotional expression, but also an invaluable tool in gaining an understanding of the clients experience, offering a boundaried environment for exploration of loss and degeneration. Finally, the paper provides a theoretical framework for the emotional experience of singing songs of personal meaning in therapy.

Music therapy with disorders of consciousness: current evidence and emergent evidence-based practice

Patients with prolonged disorders of consciousness (PDOC) stemming from acquired brain injury present one of the most challenging clinical populations in neurological rehabilitation. Because of the complex clinical presentation of PDOC patients, treatment teams are confronted with many medicolegal, ethical, philosophical, moral, and religious issues in day‐to‐day care. Accurate diagnosis is of central concern, relying on creative approaches from skilled clinical professionals using combined behavioral and neurophysiological measures. This paper presents the latest evidence for using music as a diagnostic tool with PDOC, including recent developments in music therapy interventions and measurement. We outline standardized clinical protocols and behavioral measures to produce diagnostic outcomes and examine recent research illustrating a range of benefits of music‐based methods at behavioral, cardiorespiratory, and cortical levels using video, electrocardiography, and electroencephalography methods. These latest developments are discussed in the context of evidence‐based practice in rehabilitation with clinical populations.

The role of music therapy in an interdisciplinary approach to address functional communication in complex neuro-communication disorders: A case report

Purpose. This paper presents a case report of collaborative work between speech and language therapy (SLT) and music therapy (MT) in the case of an individual presenting with complex communication difficulties and lability caused by pseudo-Parkinsonian vascular disease. Design. MT intervention was used to investigate whether participation could be enabled in a client presenting with complex problems as well as facilitate change in communication parameters which remained unresponsive to conventional SLT intervention. A single case design measured communication and well-being parameters using pre-, during and post-intervention measures. In addition, analysis of the clients musical responses was undertaken to examine changes in vocal functioning which are involved in communication. Results. Analysis of the clients performance during MT intervention revealed improvements in prosody and phonation, with positive reports of participation, reduced incidence of lability and improvements in measures of well-being. Conclusions. The results indicate the value of such collaborative working in addition to making recommendations for the modification of existing treatment protocols. The findings highlight that fatigue is a major consideration when working with people with severe and complex clinical presentations.

Music therapy with disorders of consciousness and neuroscience: the need for dialogue

Music therapy may be effective in promoting arousal and awareness for those with disorders of consciousness. This feature may be used to enhance our ability to diagnose accurately whether individuals are in vegetative or minimally conscious states. Accurate diagnosis is crucial for decisions regarding prognosis and resource allocation. However, it is a challenging process, where subtle responses to stimuli may be hard to discern through behavioural assessment alone. The literature detailing music therapy in the assessment and rehabilitation in this field spans the last 30 years, although robust research is scarce. Differences in paradigms persist in thinking about and describing clinical work with this population, where two contrasting approaches are found with humanist/music centred and behavioural/pragmatic influences. Whilst standardised behavioural assessment techniques are being developed, there is little evidence to support music therapy in rehabilitation programmes. In contrast, advances in neuroscience have improved our understanding of both brain damage and brain/music interactions. There is increasing support for the role of musical activity in promoting neuroplasticity and functional improvements for people with neuro-disabilities, although music therapy specific studies are lacking. Collaborations between the fields of neuroscience and music therapy may yield fruitful progress for both disciplines as well as for patient populations. By outlining the key findings and the remaining questions offered by the neuroscience literature, this paper sets out the future challenges to address for clinicians and researchers in developing evidence-based approaches to their work.

The complementary role of music therapy in the detection of awareness in disorders of consciousness: An audit of concurrent SMART and MATADOC assessments

In the behavioural assessment of disorders of consciousness (DOC), best practice is for several different assessment tools to be used to encourage a variety of different responses indicative of awareness. Anecdotal evidence suggests a range of musical stimuli may be particularly effective in eliciting responses to guide the assessment process, although comparative data regarding behavioural domains is lacking. This study examined 42 concurrent records of patients assessed using the Sensory Modality Assessment and Rehabilitation Technique (SMART), and the Music Therapy Assessment Tool for Awareness in Disorders of Consciousness (MATADOC) to explore the relationship between diagnosis and behavioural characteristics of the cohort. Whilst the two tools produced a high level of agreement in diagnostic outcome (Spearman Rho .80), divergent diagnosis and weaker correlations between behavioural response items highlight contrasting sensitivities of the tools. Whilst MATADOC has higher sensitivity within auditory and visual domains relative to SMART, SMART has higher sensitivity in the motor domain. The significant contribution of musical response items in MATADOC, and the tactile response item in SMART, indicates both tools provide unique behavioural data predictive of awareness. Multidisciplinary assessment using SMART and MATADOC provides complementary data contributing to a fuller understanding of a patients level of awareness.