Validation of the Music Therapy Assessment Tool for Awareness in Disorders of Consciousness With the Coma Recovery Scale-Revised.

OBJECTIVE: To examine (1) the concurrent validity of the Music Therapy Assessment Tool for Awareness in Disorders of Consciousness (MATADOC) with the criterion standard Coma Recovery Scale-Revised (CRS-R) for outcomes of awareness in patients with prolonged disorders of consciousness (PDoC), (2) the relationship between MATADOC items and CRS-R function subscales in similar domains, and (3) determine if items/function subscales measure different constructs. DESIGN: A prospective multicentric blinded study with repeated concurrent measures. SETTING: Three inpatient rehabilitation units. PARTICIPANTS: Convenience sample of 74 adults with PDoC (N=74). MAIN OUTCOME MEASURES: The MATADOC protocol elicits behavioral responsiveness using live music in 5 tasks. A total score ranges 0-10 scoring behaviors across 14-items. The CRS-R uses a language-based protocol and scores observed responses ranging from 0-23 in 6 function subscales. Both measures were delivered at 4 concurrent time points over 2 weeks. RESULTS: Fair (κ=0.238, P=.006) ranging to moderate (κ=0.419, P<.001) significant agreement was found between CRS-R and MATADOC diagnostic outcomes. Fair-borderline moderate significant agreement was found for overall diagnostic outcomes across all diagnostic categories (κ=0.397, P=.001). There was moderate significant agreement between measures for motor scores (0.551≤κ≤0.571, P<.001) and visual outcomes (0.192≤κ≤0.415, .001≤P<.005) but no agreement for item/function subscale outcomes assessing auditory responsiveness. Exploratory factor analysis of all items showed 2 factors, suggesting that MATADOC and CRS-R measure the same underlying latent variable (awareness) in different ways and could complement each other for diagnosis and intervention purposes. This was supported by scale analysis, which showed increased reliability when the 2 scales are used together rather than separately. CONCLUSIONS: Unlike the CRS-R, the music-based MATADOC scores auditory localization for complexity of response and categorizes these behaviors as conscious rather than reflexive. The MATADOC may supplement the CRS-R, having a particular role in interdisciplinary programming for providing a more robust assessment of auditory responsiveness because of using nonverbal musical stimuli.

Examining the Functionality of the MATADOC With the CRS-R: A Pilot Study.

Prolonged disorders of consciousness (PDOC) following acquired brain injury affect a person's awareness of self and the environment. Motor, communication, sensory, and cognitive deficits challenge assessment. Rigorously tested behavioral assessments, sensitive to detecting awareness, are critical for discerning a prognosis for recovery and access to treatment. The Coma Recovery Scale-Revised (CRS-R) is considered the gold standard in PDOC diagnostic assessments. This study explored preliminary concurrent validity of the Music Therapy Assessment Tool for Awareness in Disorders of Consciousness (MATADOC) with the CRS-R. The MATADOC and CRS-R were administered concurrently to 8 participants utilizing a repeated measures design. Correlations for diagnosis and item functionality were explored between and within the 2 measures. There was an adequate level of agreement between the 2 measures for overall diagnosis. Significant positive correlations were found between measures for all domains utilizing the MATADOC repeated administrations design. Within-measure relationships were significant for each of the auditory and communication domains with diagnosis for both measures, and additionally for each of the visual and arousal domains with diagnosis on the MATADOC. Both measures yielded significant inter-item relationships for auditory-visual domains, communication-visual domains, arousal-auditory domains, and arousal-visual domains. The MATADOC yielded an additional significant correlation for the auditory-communication domains. The findings have positive implications for the MATADOC as a diagnostic measure and companion assessment in cases of questionable diagnosis. Research with a larger sample is warranted. Generally, higher arousal scores on the MATADOC support music as effective in eliciting arousal, giving patients the opportunity to perform at their optimal level of function.

Dog-Assisted Therapy in Neurorehabilitation of Children with Severe Neurological Impairment: An Explorative Study.

BACKGROUND: Dog-assisted therapy (DAT) is increasingly applied in neurorehabilitation of patients with severe neurological impairments. To date, there are only anecdotal reports investigating its effects. OBJECTIVES: This study was aimed to evaluate the potential of DAT in pediatric inpatient neurorehabilitation for severely neurologically impaired children and adolescents, to identify characteristics of patients receiving this therapy, characteristics of the therapy sessions, and to evaluate feasibility and extent of goal achievement. METHODS: We retrospectively analyzed 850 DAT sessions performed between 2010 and 2017 at an inpatient neurorehabilitation center. The dataset included 196 children and adolescents (Md = 5.50, 0.58-20.33 years) suffering from severe neurological impairments (disorders of consciousness in 37 patients) of various etiologies. We extracted information regarding patient and session characteristics, analyzed the predefined goals with content analysis, and examined to what extent the goals were met during DAT. Data were analyzed using descriptive statistics. RESULTS: Patients received an average of 4.34 therapy sessions. A total of 247 of 392 predefined goals (63%) were reached during DAT. The most frequently achieved goal was "enhancing fun" (83%), followed by "establishing contact and communication" (81%), and "relaxation" (71%). Only one critical incident regarding the dogs' safety occurred. CONCLUSION: DAT is a feasible approach and appears to facilitate emotional, social, and psychological goals in children and adolescents with severe neurological impairment.

Electrodermal reactivity to emotional stimuli in healthy subjects and patients with disorders of consciousness.

OBJECTIVES: After a coma, one major challenge is the detection of awareness in patients with disorders of consciousness. In some patients, the only manifestation indicative of awareness is an appropriate emotional response. Preferred music is a powerful medium to elicit emotions and autobiographical memory. Furthermore, music has been shown to improve cognitive functions both in healthy subjects and patients with neurological impairment. We hypothesized that signs of awareness could be enhanced in some patients with disorders of consciousness under appropriate emotional stimulation such as preferred music and also probably preferred odors. METHODS: To investigate an objective, easily recordable marker of emotions at the patients' bedside, electrodermal activity (skin conductance level, SCL) was assessed with stimulations in auditory and olfactory modalities, notably with preferred music, neutral sound, preferred odors, and neutral odors. The study was conducted in 11 patients with disorders of consciousness (DOC) and 7 healthy participants. RESULTS: In healthy subjects, the mean amplitude of the SCL was increased during exposure to preferred music as compared to neutral sounds (respectively: 0.00037±0.0004 vs. - 0.00004±0.00019µS). No significant difference between conditions was detected in patients. CONCLUSION: The results of this study suggest that electrodermal activity could be a useful marker of emotions induced by music in healthy controls. However, it failed to show any significant difference between conditions in patients with DOC.

Twist and turn into chronic disorders of consciousness: Potential role of the auditory stapedial reflex.

BACKGROUND: Patients suffering from chronic disorders of consciousness (DOC), including minimally conscious state (MCS) and unresponsive wakefulness syndrome (UWS), typically show an awareness impairment paralleled by a significant reflex hyper-excitability, which depend on the cortical deafferentation following brain-damage-induced thalamocortical system deterioration. Nonetheless, recent studies have shown a residual preservation of cortico-subcortical pathways that may sustain residual fragments of awareness in some DOC patients. OBJECTIVE: The aim of our study was to assess whether the cortical modulation of auditory stapedial reflex (ASR) could be a marker of a higher degree of brain network connectivity, which is a fundamental prerequisite for awareness generation and maintenance. METHODS: We applied a repetitive transcranial magnetic stimulation (rTMS) protocol over the primary auditory area and measured the neuromodulation effects on ASR threshold (ASRt) in a DOC sample and a healthy control group (HC). RESULTS: We observed an ASRt reduction in all the HC and MCS individuals, in parallel to a better sound-induced motor responsiveness in MCS sample, while all the UWS patients, but two, did not show any significant ASRt modulation. CONCLUSION: We hypothesize that our conditioning protocol may have entrained and potentiated some spared cortico-subcortical networks that sustained the clinical and electrophysiological amelioration we found. Our data electrophysiologically demonstrate for the first time that primary the auditory area can influence ASR elicitation, and such finding may support the DOC differential diagnosis.

Brain-computer interfaces for patients with disorders of consciousness.

The disorders of consciousness refer to clinical conditions that follow a severe head injury. Patients diagnosed as in a vegetative state lack awareness, while patients diagnosed as in a minimally conscious state retain fluctuating awareness. However, it is a challenge to accurately diagnose these disorders with clinical assessments of behavior. To improve diagnostic accuracy, neuroimaging-based approaches have been developed to detect the presence or absence of awareness in patients who lack overt responsiveness. For the small subset of patients who retain awareness, brain-computer interfaces could serve as tools for communication and environmental control. Here we review the existing literature concerning the sensory and cognitive abilities of patients with disorders of consciousness with respect to existing brain-computer interface designs. We highlight the challenges of device development for this special population and address some of the most promising approaches for future investigations.

Music Therapy Assessment Tool for Awareness in Disorders of Consciousness (MATADOC): Reliability and Validity of a Measure to Assess Awareness in Patients with Disorders of Consciousness.

BACKGROUND: Prolonged Disorders of Consciousness (PDOC) describes a population where a consciousness disorder has persisted for at least four weeks post injury but is still under investigation. Complex motor, sensory, communication, and cognitive impairments cause challenges with diagnosis, assessment, and intervention planning. Developing sensitive, reliable, and valid measures is a central concern. The auditory modality is the most sensitive for identifying awareness; however, the current standardized behavioral measures fail to provide adequate screening and measurement of auditory responsiveness. The Music Therapy Assessment Tool for Awareness in Disorders of Consciousness (MATADOC) is a recently standardized measure for assessment with PDOC; however, psychometric values for two of its subscales require examination. OBJECTIVE: To determine the measurement characteristics and properties of the MATADOC subscales two and three. METHODS: In a convenience sample of 21participants with PDOC, a prospective repeated measures study examined inter-rater reliability (IRR) and test-retest reliability (TRR) for both subscales and internal consistency of subscale two. RESULTS: Overall, the items from the MATADOC subscales two and three demonstrated good agreement across and within assessors, with some variability on two identified items. CONCLUSIONS: The MATADOC is a standardized measure for assessment of auditory responsiveness in PDOC. Psychometric limitations for the two identified items may have resulted from variations in music therapist clinical experience and training, leading to variations in the administration and interpretation of PDOC patient responses to these two MATADOC assessment items. Although its psychometric properties could be improved, the MATADOC's clinimetric properties make it a valuable assessment to guide clinical work for patients with PDOC.

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.

Boosting Cognition With Music in Patients With Disorders of Consciousness.

BACKGROUND: Music listening conveys beneficial effects on cognitive processes in both normal and pathologic cerebral functioning. Surprisingly, no quantitative study has evaluated the potential effects of music on cognition and consciousness in patients with disorders of consciousness. OBJECTIVE: The aim of the present study was to evaluate the effect of music on cerebral processing in patients with disorders of consciousness. METHODS: Using bedside electroencephalographic recording, we acquired in 13 patients with disorders of consciousness event-related potentials to the patient's first name after either an excerpt of the patient's preferred music (music condition) or a continuous sound (control condition). RESULTS: The cerebral response to the patient's first name was more often observed in the music condition, than in the control condition. Furthermore, the presence or absence of a discriminative response in the music condition seemed to be associated with a favorable or unfavorable outcome, respectively. CONCLUSIONS: These findings demonstrate for the first time that music has a beneficial effect on cognitive processes of patients with disorders of consciousness. The autobiographical characteristics of music, that is, its emotional and personal relevance, probably increase arousal and/or awareness.

Effects of different musical stimuli in vital signs and facial expressions in patients with cerebral damage: a pilot study.

BACKGROUND: Along history, music has been used in a variety of ways for therapeutic purposes and has long been recognized for its physiological and psychological effects. Music listening can be an effective nursing intervention, to enhance relaxation, provide distraction, and reduce pain. OBJECTIVES: The aims of this study were to identify changes produced by different musical stimuli in blood pressure (BP), heart rate (HR), respiratory rate (RR), and oxygen saturations (SpO2) and to verify the influence of music listening on patients' facial expressions with severe cerebral damage. METHOD: A quasiexperimental study was performed in 26 patients with severe cerebral damage, divided into control and case groups. Patients belonging to the case group were exposed to musical stimuli, radio, classical relaxing music (CRM), and relaxing music with nature sounds (RMNS). Patients were evaluated by measuring vital signs before and after exposure to each musical stimulus, as were the patients within the control group. Patients in the control group were exempt from any musical stimulus. Facial expressions were observed in each patient within the case group during the intervention. RESULTS: The results show that radio produced a slight increase in systolic BP, HR, RR, and SpO2. The CRM induced a decrease of RR and an increase of SpO2 and also produced alterations of the facial expression. When RMNS was played, a decrease was displayed in BP, HR, and RR and an increase was displayed in SpO2. Alterations in facial expression were displayed in each patient. CONCLUSIONS: The results of the study suggest that the application of musical stimuli such as CRM and RMNS can be used to provide a state of relaxation in patients with severe cerebral damage.

Extending communication for patients with disorders of consciousness.

BACKGROUND AND PURPOSE: The difficulty of distinguishing disorders of consciousness from certain disorders of communication leads to the possibility of false diagnosis. Our aim is to communicate with patients with disorders of consciousness through asking them to answer questions with "yes/no" by performing mental imagery tasks using functional magnetic resonance imaging (fMRI). METHODS: A 1.5 T fMRI study with 5 patients and a control group is presented. Speech comprehension, mental imagery, and question-answer tests were performed. RESULTS: The imagery task of mental calculation produced equally distinct activation patterns when compared to navigation and motor imagery in controls. For controls, we could infer answers to questions based on imagery activations. Two patients produced activations in similar areas to controls for certain imagery tasks, however, no activations were observed for the question-answer task. CONCLUSIONS: The results from 2 patients provide independent support of similar work by others with 3 T fMRI, and demonstrate broader clinical utility for these tests at 1.5 T despite lower signal-to-noise ratio. Based on the control results, mental calculation adds a robust imagery task for use in future studies of this kind.

[Home-based rehabilitation in the functional recovery of patients with cerebrovascular disease]. / Rehabilitacion domiciliaria en la recuperacion funcional de los pacientes con enfermedad cerebrovascular.

INTRODUCTION: The study of the effectiveness of rehabilitation treatment applied to patients with sequelae following a cerebrovascular disease (CVD) plays a decisive role nowadays in planning their management in public healthcare and to improve existing guidelines regarding assessment and treatment. AIM: To describe the characteristics presented by patients who have suffered a CVD and were treated in mobile rehabilitation-physiotherapy units (MRPU) and how such treatment affects their functional recovery. PATIENTS AND METHODS: Descriptive, prospective study conducted on 124 patients referred to the MRPUs in the province of Almeria between 2008 and 2011. The variables analysed (both pre- and post-treatment) included personal history and characteristics, Barthel index, Modified Ashworth Spasticity Scale, pain (shoulder) and the Canadian Neurological Scale. RESULTS: The final sample consisted of 106 participants (mean age: 73.72 years). The disabling process was ischaemic in 77.4% and hypertension was the most prevalent risk factor (81%). The mean initial Barthel index was 31.04 and the mean final index was 57.62 (t = -11.75; p < 0.001). The Canadian Neurological Scale showed a favourable progression in the level of consciousness, orientation and language (p < 0.001). Altogether 56.2% of the patients were discharged as a result of the improvement of their condition, and did not require any further outpatient rehabilitation. CONCLUSIONS: The results obtained reflect an important functional improvement in patients treated in the MRPUs. Home-based rehabilitation is considered a necessary tool for persons with greater clinical vulnerability and no access to outpatient care, which provides them with the benefits of effective treatment.

TITLE: Rehabilitacion domiciliaria en la recuperacion funcional de los pacientes con enfermedad cerebrovascular.Introduccion. El estudio de la eficacia en los tratamientos de rehabilitacion aplicados a pacientes con secuelas tras una enfermedad cerebrovascular (ECV) resulta decisivo en la actualidad para planificar su abordaje desde la sanidad publica y mejorar las directrices de evaluacion y tratamiento existentes. Objetivo. Describir las caracteristicas que presentan los pacientes que han sufrido ECV atendidos por las unidades moviles de rehabilitacion-fisioterapia (UMRF) y como influyen estos tratamientos sobre su recuperacion funcional. Pacientes y metodos. Estudio descriptivo prospectivo en 124 pacientes derivados a las UMRF de la provincia de Almeria entre 2008 y 2011. Se analizaron variables (pre y postratamiento) como las caracteristicas y antecedentes personales, indice de Barthel, escala de espasticidad de Ashworth modificada, dolor (hombro) y escala neurologica canadiense. Resultados. La muestra final estuvo compuesta por 106 participantes (edad media: 73,72 años). El proceso discapacitante fue isquemico en un 77,4%, y la hipertension, el factor de riesgo mas prevalente (81%). La media del indice de Barthel inicial fue de 31,04, y la media del indice final, de 57,62 (t = ­11,75; p < 0,001). La escala canadiense mostro una evolucion favorable en el nivel de conciencia, orientacion y lenguaje (p < 0,001). El 56,2% de los pacientes recibio alta por mejoria, sin precisar rehabilitacion ambulatoria adicional. Conclusiones. Los resultados obtenidos reflejan una importante mejora funcional en los pacientes tratados en las UMRF. La rehabilitacion domiciliaria se plantea como una herramienta necesaria para las personas con mayor vulnerabilidad clinica y sin acceso a los cuidados ambulatorios, que logra los beneficios de tratamientos que son efectivos.

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 patient's level of awareness.

[Rehabilitation of children after craniocerebral injuries with particular attention paid to the reflex stimulation Powiertowski's method. Preliminary study]. / Usprawnianie dzieci po przebytych urazach czaszkowo-mózgowych ze szczególnym uwzglednieniem metody stymulacji odruchowej Hieronima Powiertowskiego. Doniesienie wstepne.

INTRODUCTION: An increasing number of craniocerebral injuries among children is becoming a serious therapeutic problem for emergency wards and for chronic treatment wards. The most important problem among these patients is a lengthening period of consciousness disorders. The aim of the study is to present a sample method of rehabilitation of children with brain injury. MATERIAL AND METHODS: The rehabilitation process comprised 15 children with brain injury, including 8 with cerebral hemisphere injury and 7 with brain stem injury. The method of early motion rehabilitation was applied. It was developed by H. Powiertowski in 1970's. In the years 1991-1999 the method was used at the Children's Ward of the Department of Rehabilitation by Professor Krystyna Dobosiewicz. RESULTS: As a result of the applied method, 13 out of 15 children with brain injuries regained consciousness. 2 girls with severe lesion of the brain, still unconscious were transferred to the intensive care ward in the place of residence. CONCLUSIONS: Powiertowski's method of motion stimulation, which is presented in this paper, turned out to be successful in the process of rehabilitation children with brain injury treated in the Department of Rehabilitation.

Classical conditioning in the vegetative and minimally conscious state.

Pavlovian trace conditioning depends on the temporal gap between the conditioned and unconditioned stimuli. It requires, in mammals, functional medial temporal lobe structures and, in humans, explicit knowledge of the temporal contingency. It is therefore considered to be a plausible objective test to assess awareness without relying on explicit reports. We found that individuals with disorders of consciousness (DOCs), despite being unable to report awareness explicitly, were able to learn this procedure. Learning was specific and showed an anticipatory electromyographic response to the aversive conditioning stimulus, which was substantially stronger than to the control stimulus and was augmented as the aversive stimulus approached. The amount of learning correlated with the degree of cortical atrophy and was a good indicator of recovery. None of these effects were observed in control subjects under the effect of anesthesia (propofol). Our results suggest that individuals with DOCs might have partially preserved conscious processing, which cannot be mediated by explicit reports and is not detected by behavioral assessment.

Electrical treatment of reduced consciousness: experience with coma and Alzheimer's disease.

The right median nerve can be stimulated electrically to help arouse the central nervous system for persons with reduced levels of consciousness. The mechanisms of central action include increased cerebral blood flow and raised levels of dopamine. There is 11 years of experience in the USA of using nerve stimulation for acute coma after traumatic brain injury. There is a much longer period of experience by neurosurgeons in Japan with implanted electrodes on the cervical spinal cord for persons in the persistent vegetative state (PVS). But the use of right median nerve electrical stimulation (RMNS) for patients in the subacute and chronic phases of coma is relatively new. Surface electrical stimulation to treat anoxic brain injury as well as traumatic brain injury is evolving. Novel applications of electrical stimulation in Amsterdam have produced cognitive behavioural effects in persons with early and mid-stage Alzheimer's disease employing transcutaneous electrical nerve stimulation (TENS). Improvements in short-term memory and speech fluency have also been noted. Regardless of the aetiology of the coma or reduced level of awareness, electrical stimulation may serve as a catalyst to enhance central nervous system functions. It remains for the standard treatments and modalities to retrain the injured brain emerging from reduced levels of consciousness.