Music therapists may have a unique role to play in the assessment of patients in LAS. Accurate distinction between VS and MCS is difficult, evidenced by a 37%-43% misdiagnosis rate (Andrews, Murphy, Munday, & Littlewood, 1996; Beaumont & Kenealy, 2005; Childs, Mercer, & Childs, 1993), but has significant implications for funding, treatment, prognosis, and medico-legal judgments (Giacino et al., 2002). Distinguishing between purposeful and reflexive responses is particularly difficult using purely behavioral observation due to the small and inconsistent nature of responses typical of this population (Gill-Thwaites & Munday, 2004). The use of specialized assessment tools and procedures designed to quantitatively measure levels of consciousness may be helpful (Giacino et al., 2002). Some commonly used generic instruments include:
• Glasgow Coma Scale (GCS) (Teasdale & Jennett, 1974) • Glasgow Outcome Scale (GOS) (Jennett & Bond, 1975)
• Coma Recovery Scale-Revised (CRS) (Giacino & Kalmar, 2006)
• Disability Rating Scale (DRS) (Rappaport, Hall, Hopkins, & Belleza, 1982) • Wessex Head Injury Matrix (WHIM) (Shiel et al., 2000)
• Rappaport Coma/Near Coma Scale (Rappaport, Dougherty, & Kelting, 1992) • Ranchos Los Amigos Scale (Hagen, Malkmus, & Axen, 1989),
• Sensory Modality Assessment and Rehabilitation Technique (SMART) (Gill-Thwaites & Munday, 2004)
Previous music therapy research using generic assessment tools (CRS and DRS) to assess the effect of music therapy interventions with LAS patients found these lacking in sensitivity (Formisano et al., 2001). Magee and colleagues have recently developed a specific music therapy assessment tool for low awareness states: MATLAS (Daveson, 2010; Daveson, Magee, Crewe, Beaumont, & Kenealy, 2007; Magee, 2007). This standardized instrument has been designed to be sensitive enough to measure the subtle responses of patients in LAS to music therapy intervention and has been successfully used to differentiate between MCS and VS diagnoses (Magee, 2005). Specialized assessor training is required prior to use of the tool and training courses are provided by the Royal Hospital for Neuro-disability in London (www.rhn.org.uk/events/courses-and-training). The MATLAS assesses 14 behavioral response categories
covering the five commonly assessed behavioral domains; motor, communication, arousal, auditory, and visual responses. “Each item is categorized into levels of observed behavioral responses with a numerical grading,” where zero indicates “no response” (Magee, 2007, p. 321). Definitions of observable behaviors for each level are provided in the MATLAS Assessment Manual. These categories are combined to provide three summed categories. Category 1, “essential diagnostic criteria,” combines five behavioral response categories relating directly to diagnostic features of VS and MCS and synthesizes these into a single diagnostic descriptive statement. Category 2 describes patient musical parameter preference and behavioral response type, and category 3 provides clinical information that can be used for goal-setting and treatment planning. A MATLAS assessment is usually conducted over four sessions within 8 to 10 days and involves the controlled presentation of live music, both familiar and novel, using a range of musical stimuli and instruments (Daveson et al., 2007). For example, “the item ‘Responses to auditory stimuli’ records localizing and tracking behaviours. ... The auditory stimuli presented vary from simple single musical sounds to more complex musical stimuli that can be subtly manipulated in parameters such as pitch and volume” (Magee, 2007 , p. 322). Music’s independence from language renders it an ideal medium to use in both assessment and therapeutic intervention with patients who are not capable of verbal communication. It has been suggested that key elements of music, such as pulse, tempo, and rhythm, are able to influence physiological outcomes through entrainment of the respiratory and cardiovascular systems (Magee, 2005). In addition, the nonverbal capacity and emotional power of music are the crucial aspects used therapeutically to engage patients and stimulate behavioral and communicative responses.
Post-Traumatic Amnesia
As discussed in the previous section, PTA patients in the critical care setting are usually referred for music therapy to address behavioral symptoms such as agitation, impulsivity, and disorientation, as these place PTA patients at greatest risk in terms of medical management.
In Australia, orientation is usually assessed using the Westmead PTA Scale (Shores, Marosszeky, Sandanam, & Bachelor, 1986). This scale consists of seven orientation questions and five memory questions to produce a score out of 12. When a person achieves a score of 12 for three consecutive days, they are considered to have emerged from PTA. Another widely used orientation scale used in PTA is the Galveston Orientation and Amnesia Test (GOAT; Levin, O'Donnell, & Grossman, 1979). Agitation can be measured through observation or by completing a behavioural checklist such as the Agitated Behaviour Scale (Corrigan, 1989), which has high validity and inter-rater reliability (Corrigan & Bogner, 1994). The Agitated Behaviour Scale contains 14 items describing agitated behaviours. The rater is required to assign each item a score of between 1 and 4 and add the scores together to obtain an overall score. A total score of 14 indicates an absence of agitation, and 56 is the highest possible agitation score. Any score greater than 36 is indicative of severe agitation. This scale can be used to track agitation from pre- to postsession and/or over time.
Mechanical Ventilation
The primary reason for referring mechanically ventilated patients to music therapy is anxiety management. State anxiety can be assessed using standardized tools such as the State-Trait Anxiety Measure (STAI; Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983), the Beck Anxiety Inventory (BAI; Beck & Steer, 1990), and the Hospital Anxiety and Depression Scale-Anxiety (HADS-A; Zigmond & Snaith, 1983). Other outcome measures may include sedative drug intake and physiological outcomes such as heart rate, respiratory rate, blood pressure, airway pressure, and oxygen saturation.
O
VERVIEW OFM
USICT
HERAPYM
ETHODSMusic therapists in critical care units commonly use the following methods and procedures. These have not been sequenced to reflect relative significance, effectiveness, or complexity.
Receptive Music Therapy
• Presentation of Familiar Music: Music therapist provides live or recorded music for client to listen to.
Improvisational Music Therapy
• Therapist-Improvised Music: Music therapist improvises music based on the changing physiological rhythms and responses of the patient in an attempt at creating mutuality.
•
Client/Therapist Vocal/Instrumental Improvisation: Active musical participation fromboth client and therapist
.
Re-creative Music Therapy
•
Lyric completion: The use of live, familiar music to prompt song line completion.
G
UIDELINES FORR
ECEPTIVEM
USICT
HERAPYReceptive music therapy traditionally encompasses techniques in which the patient is a recipient of the music experience, as distinct from active music-making (Grocke & Wigram, 2007). According to Bruscia (1998), in receptive music therapy experiences, the patient listens to music and responds silently or in another modality. However, for some of the interventions included the following section on receptive music therapy, the therapeutic goal is to actively engage the patient and stimulate purposeful (sometimes musical) responses. This may seem to be the antithesis of receptive music therapy, but these interventions are positioned in the following section due to the presentation of familiar music to the patient, as opposed to music improvised or re-created with the patient.
Assessment of music preferences can be challenging in the critically-ill population due to communication difficulties or inability. If the patient has CDs or an MP3 player in their room, this may be used to form an initial picture of the patient’s musical tastes. Consultation with the patient’s family and friends may be able to further complete this picture. If none of the above are possible, determine the patient’s age and begin by using popular songs from their young adult life that are therapeutically appropriate.