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ISSN 2526-8910Cad. Bras. Ter. Ocup., São Carlos, v. 27, n. 4, p. 873-884, 2019https://doi.org/10.4322/2526-8910.ctoAR1909
Rev
iew
Art
icle
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author: Thanires Rafaele Menezes Soares dos Santos, Hospital Universitário, Universidade Federal do Maranhão, Rua Barão de Itapari, 227, Centro, CEP 65020-070, São Luís, MA, Brasil, e-mail: [email protected] on Mar. 15, 2019; Accepted on May 16, 2019.
Abstract: Introduction: Music therapy is widely used for treatment and care in various diseases including disorders of consciousness, dementia, stroke, psychiatric disorders, Parkinson’s disease, pain of several origins among others. It is known that listening to music influences mood and arousal, which can improve performance on a variety of cognitive tasks. Objective: To analyze the information available in the literature about scientific evidences of the use of music as a therapeutic resource. Method: This is an integrative review with search of articles published in national and international journals indexed in databases and journal banks: Pubmed, Cinahl, Web of Science and SciELO, between December/2017 and January/2018. We used the descriptors “music” and “disorders of consciousness” in Portuguese, English and Spanish. Results: We selected 14 heterogeneous studies with good methodological quality, among which we highlight interventional and observational studies with a degree of recommendation A. Conclusion: The study concludes to exist some evidence in the scientific literature about the effectiveness and efficacy of music therapy in the treatment and evaluation of people in coma, minimally conscious states and persistent vegetative state.
Keywords: Music, Art Therapy, Consciousness Disorders.
Terapia musical em pacientes com distúrbios da consciência: uma revisão integrativa
Resumo: Introdução: A terapia com música é amplamente utilizada para tratamento e assistência em várias doenças, incluindo distúrbios da consciência, demência, acidente vascular cerebral, distúrbios psiquiátricos, Parkinson, dor de origens diversas, entre outros. Sabe-se que ouvir música influencia o humor e a excitação, o que pode melhorar o desempenho em uma variedade de tarefas cognitivas. Objetivo: Analisar as informações disponíveis na literatura sobre as evidências científicas do uso da música como recurso terapêutico. Método: Trata-se de uma revisão integrativa com buscas de artigos publicados em periódicos nacionais e internacionais indexados nas bases de dados e banco de revistas: Pubmed, Cinahl, Web of Science e SciELO, entre dezembro/2017 e janeiro/2018. Utilizou-se os descritores “música” e “distúrbios da consciência” de forma associada em português, inglês e espanhol. Resultados: Foram selecionados 14 estudos heterogêneos, porém com boa qualidade metodológica, dentre os quais se destacam estudos intervencionais e observacionais com grau de recomendação A. Conclusão: O estudo concluiu haver na literatura científica algumas evidências da efetividade e da eficácia da terapia musical no tratamento e avaliação de pessoas em coma, estados minimamente conscientes e estado vegetativo persistente.
Palavras-chave: Música, Terapia pela Arte, Transtorno da Consciência.
Music therapy in patients with disorders of consciousness: an integrative review
Thanires Rafaele Menezes Soares dos Santos , Tamires Barradas Cavalcante , João Ferreira Silva Junior
Hospital Universitário, Universidade Federal do Maranhão – UFMA, São Luís, MA, Brasil.
a
Cad. Bras. Ter. Ocup., São Carlos, v. 27, n. 4, p. 873-884, 2019
874874/884 Music therapy in patients with disorders of consciousness: an integrative review
1 Introduction
Therapy with music is widely used for treatment and assistance in various diseases, including disorders of consciousness, dementia, stroke, psychiatric disorders, Parkinson’s disease, pain of various origins, among others (O’KELLY et al., 2014).
We know that listening to music influences mood and arousal, which can improve performance in a variety of cognitive tasks-called “Mozart effect” or “hypothesis of humor and arousal” (ROLLNIK; ALTENMÜLLER, 2014).
Music therapists and other health professionals has been using music in the field of health as another recourse in their professional practice (MORGAN, 2017). In the last 20 years, the number of researches about the use of music or music therapy in the hospital context has increased significantly, including a wide range of results in several of specialties (KAMIOKA et al., 2014).
As a non-pharmacological technique, music provides several benefits and is a low-cost therapy when compared with the costs of other therapies (GLASZIOU, 2015). The use of music, because it is a cheap technology and provides the improvement of the patient’s experience, makes the question of using music in different contexts seem obvious, however the best way to use music in hospitals does not seem to be clear to the multiprofessional team, especially on their use in comatose patients.
Music therapy in people with disorders of consciousness (DC) has a long history, from the pioneering work of Professor Mary Boyle in 1983 (BOYLE; GREER, 1983) to current developments in diagnostic, evaluation and evidence-based interventions (O’KELLY et al., 2013). Despite the longevity of this investigation and the breadth of explored approaches, the literature on the use of music therapy in meeting the clinical needs of this population, as a way to improve empirical evidence, remains scarce.
Dr. Aldridge, in the 90 decade, suggested that improvised music therapy could be a useful adjuvant therapy in such situations, both for the patient and for the team. He quoted a case where a music therapist started working with comatose patients. They treated five patients, between 15 and 40 years old, with severe coma (a Glasgow Coma Scale score between 4 and 7). Each music therapy contact lasted between 8 and 12 minutes. The therapist improvised his learning without words based on the rhythm of the patient’s pulse and, more relevant, in the patient’s breathing pattern (ALDRIDGE;
GUSTORFF; HANNICH, 1990). There were a number of reactions such as breathing change (it became slower and deeper), fine motor movements, claw hand movements and turning the head, the eyes opening to regain consciousness. When the therapist started singing, the heart rate slowed down. Then the heart rate increased rapidly and sustained a high level until the end of the contact. This effect, which indicates arousing and perceptive activity, disappeared after music therapy stopped (ALDRIDGE; GUSTORFF; HANNICH, 1990).
The demonstration of the efficacy of music required a scale or sufficiently sensitive measures to show behavioral changes in a population as complex as patients with disorders of consciousness (DC). This was the challenge that led to the development and standardization of the Music Therapy Assessment tool for awareness of disorders of consciousness or MATADOC (MAGEE et al., 2014). This measure can demonstrate behavioral signs of responsiveness to auditory stimuli in the person with disorders of consciousness; nowadays MATADOC is the most relevant assessment tool due to the diagnostic value, relevant to the interdisciplinary care of these patients.
In view of the comprehension of the therapeutic potential of music, it is hypothesized the possible efficacy and efficiency of its use in patients with DC. Due to the lack of knowledge of professionals about how to perform this practice, as well as the little elucidation about its use in different contexts, especially in hospital institutions, this review study intends to analyze the scientific evidences available in the literature on the use of music as a therapeutic resource in patients with DC.
2 Method
This is an integrative review, whose purpose is to gather and synthesize research results on a specific topic or subject, in a systematic and orderly manner, thus contributing to the complete comprehension of the theme studied. In order to operationalize this integrative review, we used the following methodological steps: Definition of inclusion and exclusion criteria; Definition of the information to extract from the selected studies; Categorization of studies; Analysis and interpretation of data; Evaluation of the results included in the integrative review and presentation of the review/synthesis of knowledge (SILVA; MENEZES, 2005).
We searched, between December/2017 and January/2018, for articles published in national and international journals indexed in the following
Cad. Bras. Ter. Ocup., São Carlos, v. 27, n. 4, p. 873-884, 2019
875875/884Santos, T. R. M. S.; Cavalcante, T. B.; Silva Junior, J. F.
databases and magazines: Pubmed, Cinahl, Web of Science and SciELO. We obtained the texts in full by electronic means in the CAPES portal of journals with access obtained through the Universidade Federal do Maranhão (UFMA). We used the descriptors in Health Sciences (HSDe): “music” and “disorders of consciousness”, in Spanish “música” y “trastornos de la consciencia” and their correspondents in English by the Medical Subject Headings (MesH) “music” and “consciousness disorders”, in an associated way.
We selected the articles according to the following inclusion criteria: presence of the descriptors chosen in the title of the paper or in the abstract; articles available in full; productions in English, Spanish and Portuguese, published between January 2013 and January 2018; sample of the studies comprised of adults and elderly people. As exclusion criterion, we filtered studies associating the use of music with another technique or therapy. We did not include secondary studies (systematic reviews, meta-analyses or literature reviews), as well as studies conducted with pediatric and neonatal population.
After the application of the above criteria, we found 171 articles (107 in PubMed, 53 in Web of Science, 02 in Scielo, 09 in Cinahl). From PubMed we selected 07 articles, in Web of Science 01 article, in Scielo 02 articles and in Cinahl 04 articles, 14 articles that we included in the sample. We discarded 157 articles and 56 articles appeared repeatedly in more than one database, 45 did not have access to the full text, 35 referred to neonates and children and 21 were secondary studies.
To catalog the articles and later evaluation, we elaborated a data collection instrument. The instrument consisted of: name of the journal, year of publication, area of knowledge, origin of the article, title of the article, objectives, type of study, characteristics of the sample, instruments and variables studied, level of evidence and degree of recommendation. We performed the analyses through reading and grouping the articles based on the elaborated instrument. We showed the findings in the form of tables and in descriptive language. The base of level of evidence and degree of recommendation was the Oxford Centre for Evidence-based Medicine (CENTRE..., 2009) scale due to its diversity of evidence classification by types of studies.
3 Results
The results show that studies about music therapy in disorders of consciousness are heterogeneous, that there are few worldwide researchers in the area,
and some stand out such as Wendy L. Magee, a researcher at Temple University in Philadelphia-USA, with many studies in the area, some included in Table 1 - characterization of the selected studies.
In Table 2 - findings of the studies, we classified them as to their highest level of evidence and their highest degree of recommendation according to the Oxford Centre for Evidence-based Medicine scale. The findings in Table 2 follow the same order of the studies in Table 1.
All selected studies focused on the properties of arousal, attention and mood activation by music therapy. The method used in all studies was stimulation by auditory pathway and without the presence of other noise in the environment.
4 Discussion
4.1 Performance of music in the Central Nervous System
When an individual is exposed to music, the sound stimulates the cochlea, medulla oblongata to the auditory cortex, promoting arousal and attention in the patient activating the thalamus, anterior cingulate gyrus and the dorsolateral prefrontal cortex. According to the type of music and melody (chords), there will be emotional stimulation (limbic and paralytic system: internal surfaces of the frontal lobes, cingulate gyrus, amygdala, hippocampus and Mesencephalon), in normal individuals there will be cognitive improvement, motor performance and humor (ROLLNIK; ALTENMÜLLER, 2014).
In patients with conscious disorders, the responses will be as below.
Heine et al. (2015), when studying the auditory response during musical stimulation, observed that the auditory network showed significant functional connectivity with the left pre-central gyrus and the dorsolateral left prefrontal cortex in the group of patients exposed to music compared to the control group of patients. The external network in patients was restricted to the sulcus and lower lobes, dorsolateral, middle frontal and supramarginal during the control and music conditions.
Riganello et al. (2015), in his controlled clinical trial, verified the influence of music on the autonomic nervous system and concluded that the type of music and musical parameters alters and stimulates different emotional responses in patients with DC. Listening to music is a complex experience and the ability to respond to musical stimuli depends on a strong individual variability. The close relationship
Cad. Bras. Ter. Ocup., São Carlos, v. 27, n. 4, p. 873-884, 2019
876876/884 Music therapy in patients with disorders of consciousness: an integrative review
Tabl
e 1.
Cha
ract
eriz
atio
n of
the
sele
cted
stud
ies.
Ord
erJo
urna
lK
now
ledg
e ar
eaSt
udy
orig
inT
itle
Obj
ectiv
eSa
mpl
e1
Arc
hive
s of
Phys
ical
Med
icin
e an
d R
ehab
ilita
tion
Med
icin
eEn
glan
dM
usic
The
rapy
Ass
essm
ent
Tool
for A
war
enes
s in
diso
rder
s of
con
scio
usne
ss d
isor
ders
: as
sess
men
t of a
war
enes
s in
diso
rder
of c
onsc
ious
ness
To in
vest
igat
e th
e ps
ycho
met
ric
prop
ertie
s of t
he m
usic
ther
apy
asse
ssm
ent t
ool f
or a
war
enes
s in
dis
orde
rs o
f con
scio
usne
ss
(MAT
AD
OC
).
21 a
dults
2B
razi
lian
Nur
sing
M
agaz
ine
Nur
sing
Bra
zil
Patie
nts w
ith d
isor
der o
f co
nsci
ousn
ess:
vita
l res
pons
es,
faci
al a
nd m
uscu
lar w
ith m
usic
or
mes
sage
10
To c
ompa
re V
ital s
igns
, fa
cial
exp
ress
ion
and
basa
l el
ectro
neur
ogra
phic
sign
s with
m
easu
rem
ents
dur
ing
mus
ic,
mes
sage
or “
sile
nce”
stim
uli i
n co
ma,
ve
geta
tive
or se
date
d st
ate
patie
nts.
76 p
atie
nts i
n 3
grou
ps:
Mus
ic: 3
0M
essa
ges:
26
Sile
nce:
20
3Eu
rope
an R
evie
w
for M
edic
al a
nd
Phar
mac
olog
ical
Sc
ienc
es
Med
icin
eC
hina
Mus
ic th
erap
y fo
r com
a Pa
tient
s:
prel
imin
ary
resu
ltsTo
app
ly q
uant
itativ
e EE
G (v
alor
δ +
θ
/ α +
β) a
nd v
alue
GC
S to
ass
ess t
he
role
of m
usic
ther
apy
in p
atie
nts i
n tra
umat
ic c
oma
due
to b
rain
inju
ry.
40Ex
perim
enta
l gro
up =
20
Con
trol g
roup
= 2
0
4Fr
ontie
rs in
Ps
ycho
logy
Psyc
holo
gyB
elgi
umEx
plor
atio
n of
func
tiona
l co
nnec
tivity
dur
ing
stim
ulat
ion
of fa
vorit
e m
usic
in p
atie
nts w
ith
diso
rder
s of c
onsc
ious
ness
To in
vest
igat
e ho
w m
usic
mod
ifies
th
e fu
nctio
nal c
onne
ctiv
ity o
f th
e br
ain
in th
e di
stur
banc
e of
co
nsci
ousn
ess.
5 Pa
tient
s exp
osed
to a
cla
ssic
fu
nctio
nal c
onne
ctiv
ity sc
an
and
a sc
an w
hile
they
wer
e ex
pose
d to
thei
r fav
orite
song
s.5
Fron
tiers
in
Neu
rosc
ienc
eN
euro
scie
nce
Italy
How
can
mus
ic in
fluen
ce th
e au
tono
mic
ner
vous
syst
em
resp
onse
in p
atie
nts w
ith se
vere
co
nsci
ousn
ess d
isor
der?
To a
naly
ze th
e au
tono
mic
resp
onse
to
mus
ical
stim
uli b
y m
eans
of
norm
aliz
ed p
aram
eter
s of l
ow
freq
uenc
y (n
uLF)
and
Ent
ropy
sa
mpl
e (S
ampE
n) o
f par
amet
ers o
f H
eart
Rat
e Va
riatio
n (H
RV) a
nd it
s po
ssib
le c
orre
latio
n w
ith th
e co
mpl
ex
diffe
renc
e of
four
mus
ic sa
mpl
es (f
or
exam
ple,
Mus
sorg
sky,
Tch
aiko
vsky
, G
rieg
and
Boc
cher
ini)
in h
ealth
y in
divi
dual
s and
pat
ient
s with
di
sord
ers o
f con
scio
usne
ss.
18 p
atie
nts
Expe
rimen
tal g
roup
= 9
in
divi
dual
s with
DC
Con
trol g
roup
= 9
hea
lthy
indi
vidu
als.
Sour
ce: A
utho
rs.
Cad. Bras. Ter. Ocup., São Carlos, v. 27, n. 4, p. 873-884, 2019
877877/884Santos, T. R. M. S.; Cavalcante, T. B.; Silva Junior, J. F.
Ord
erJo
urna
lK
now
ledg
e ar
eaSt
udy
orig
inT
itle
Obj
ectiv
eSa
mpl
e6
Neu
rops
ycho
logi
cal
Reh
abili
tatio
nN
euro
psyc
holo
gyU
nite
d St
ates
Mus
ic T
hera
py A
sses
smen
t To
ol fo
r aw
aren
ess o
f dis
orde
rs
ofco
nsci
ousn
ess (
MAT
AD
OC
): st
anda
rdiz
atio
n of
the
mai
n su
bsca
le to
ass
ess c
onsc
ious
ness
in
pat
ient
s with
dis
orde
rs o
f co
nsci
ousn
ess
To e
xam
ine
the
psyc
hom
etric
pr
oper
ties o
f the
mai
n su
bsca
le o
f a
tool
for m
usic
ther
apy
eval
uatio
n (M
ATA
DO
C) d
evel
oped
for u
se
in a
dult
patie
nts w
ith d
isor
ders
of
cons
ciou
snes
s.
21 p
atie
nts
7Fr
ontie
rs in
Hum
an
Neu
rosc
ienc
eN
euro
scie
nce
Engl
and
Neu
roph
ysio
logi
cal a
nd
beha
vior
al re
spon
ses t
o m
usic
th
erap
y in
veg
etat
ive
and
min
imal
ly c
onsc
ious
stat
es
To c
ompa
re E
lect
roen
ceph
alog
ram
(E
EG),
hear
t rat
e va
riabi
lity,
br
eath
ing
and
beha
vior
al re
spon
ses
of 2
0 he
alth
y in
divi
dual
s with
21
indi
vidu
als i
n ve
geta
tive
or
min
imal
ly c
onsc
ious
stat
es e
xpos
ed
to m
usic
ther
apy.
Expe
rimen
tal g
roup
= 2
1C
ontro
l gro
up =
20
8Jo
urna
l of
Neu
rolo
gyN
euro
logy
Italy
Act
ive
appr
oach
of m
usic
ther
apy
in C
onsc
ious
ness
dis
orde
rs: a
se
ries o
f con
trolle
d ob
serv
atio
nal
case
s
To e
valu
ate
the
effe
cts o
f act
ive
mus
ic th
erap
y (A
MT)
on
som
e ph
ysio
logi
cal p
aram
eter
s and
be
havi
oral
resp
onse
s in
diso
rder
s of
cons
ciou
snes
s.
10 p
atie
nts (
5 W
ith c
ereb
ral
anox
ia, 4
with
cer
ebra
l he
mor
rhag
e an
d 1
with
TB
I)
divi
ded
into
2 g
roup
s. G
1 w
ith
4 pa
tient
s with
Gla
sgow
Com
a Sc
ale
4 an
d G
2 w
ith 6
pat
ient
s w
ith E
CG
2.
9Jo
urna
l of M
usic
Th
erap
yM
usic
ther
apy
Engl
and
Mus
ic T
hera
py A
sses
smen
t Too
l fo
r aw
aren
ess i
n di
sord
ers o
f co
nsci
ousn
ess (
MAT
AD
OC
): re
liabi
lity
and
valid
ity o
f a
mea
sure
to a
sses
s aw
aren
ess
in p
atie
nts w
ith d
isor
ders
of
cons
ciou
snes
s
To d
eter
min
e th
e m
easu
rem
ent
char
acte
ristic
s and
pro
perti
es o
f su
bsca
les 2
and
3 o
f the
que
stio
nnai
re
MAT
AD
OC
.
21 p
atie
nts w
ith d
isor
ders
of
cons
ciou
snes
s
10N
euro
reha
bilit
atio
n an
d N
eura
l Rep
air
Neu
rore
habi
litat
ion
Fran
ceB
oost
ing
cogn
ition
with
mus
ic
in p
atie
nts w
ith d
isor
ders
of
cons
ciou
snes
s
To e
valu
ate
the
effe
ct o
f mus
ic o
n br
ain
proc
essi
ng in
pat
ient
s with
di
sord
ers o
f con
scio
usne
ss.
13 p
atie
nts w
ith d
isor
ders
of
cons
ciou
snes
s
Sour
ce: A
utho
rs.
Tabl
e 1.
Con
tinue
d...
Cad. Bras. Ter. Ocup., São Carlos, v. 27, n. 4, p. 873-884, 2019
878878/884 Music therapy in patients with disorders of consciousness: an integrative review
Ord
erJo
urna
lK
now
ledg
e ar
eaSt
udy
orig
inT
itle
Obj
ectiv
eSa
mpl
e11
Rev
ue
Neu
rolo
giqu
eN
euro
logy
Fran
ceB
enefi
cial
effe
ct o
f pre
ferr
ed
mus
ic o
n co
gniti
ve fu
nctio
ns in
pa
tient
s with
a st
ate
of m
inim
um
cons
ciou
snes
s
To c
ompa
re th
e ef
fect
of t
he
patie
nt’s
favo
rite
mus
ic w
ith a
noth
er
cont
inuo
us so
und
(con
trol)
on th
e re
latio
nal b
ehav
ior o
f pat
ient
s in
min
imal
stat
e of
con
scio
usne
ss
(MSC
).
6 pa
tient
s
12Fr
ontie
rs in
N
euro
scie
nce
Neu
rosc
ienc
eA
ustri
aN
euro
scie
ntifi
c an
d ne
uroa
nthr
opol
ogic
al p
ersp
ectiv
es
in th
e re
sear
ch a
nd p
ract
ice
of
mus
ic th
erap
y w
ith p
atie
nts w
ith
diso
rder
s of c
onsc
ious
ness
5
To d
iscu
ss th
e re
leva
nce
of th
e ne
uroa
nthr
opol
ogic
al p
ersp
ectiv
e ab
out o
ur w
ay o
f obt
aini
ng
know
ledg
e an
d its
influ
ence
on
ther
apeu
tic p
ract
ice.
Not
app
licab
le
13In
terd
isci
plin
ary
Inte
rdis
cipl
inar
yA
rgen
tina
Mus
ic th
erap
eutic
inte
rven
tions
fo
r the
act
ivat
ion
of th
e re
ticul
ar
syst
em
To d
escr
ibe
the
diffe
rent
alte
red
stat
es o
f con
scio
usne
ss a
nd th
e in
terv
entio
ns th
at u
se so
und
and
its e
lem
ents
in th
e di
agno
stic
and
th
erap
eutic
app
roac
h of
pat
ient
s in
a st
ate
of m
inim
al c
onsc
ious
ness
and
th
eir e
ffect
on
retic
ular
form
atio
n.
Not
app
licab
le
14Fr
ontie
rs in
Ps
ycho
logy
Psyc
holo
gyU
nite
d St
ates
Sens
ory
stim
ulat
ion
prog
ram
s and
m
usic
ther
apy
to tr
eat d
isor
ders
of
cons
ciou
snes
s
To ta
lk a
bout
sens
ory
stim
ulat
ion
prog
ram
s and
mus
ic th
erap
y to
trea
t di
sord
ers o
f con
scio
usne
ss
Not
app
licab
le
Sour
ce: A
utho
rs.
Tabl
e 1.
Con
tinue
d...
Cad. Bras. Ter. Ocup., São Carlos, v. 27, n. 4, p. 873-884, 2019
879879/884Santos, T. R. M. S.; Cavalcante, T. B.; Silva Junior, J. F.
Tabl
e 2.
Stu
dy fi
ndin
gs.
Ord
erA
utho
r/ye
arT
ype
of s
tudy
Res
ults
/ C
oncl
usio
nLe
vel o
f ev
iden
ceD
egre
e of
re
ccom
men
datio
n1
Mag
ee e
t al.
(201
7)In
terv
entio
nal-
doub
le b
lind
cont
rolle
d cl
inic
al
trial
The
auth
ors c
oncl
uded
that
aud
itory
resp
onsi
vene
ss is
the
mai
n fa
ctor
in th
e re
spon
ses t
o st
imul
i pro
voke
d by
mus
ic in
pat
ient
s with
DC
1BA
2Pu
ggin
a an
d Si
lva
(201
5)C
ross
-sec
tiona
lSt
atis
tical
ly s
igni
fican
t alte
ratio
ns in
the
varia
bles
tem
pera
ture
, fac
ial
expr
essi
on, e
lect
rone
urom
yogr
aphy
and
Gla
sgow
Sca
le; m
ore
freq
uent
al
tera
tions
in s
essi
on 2
, in
patie
nts
with
com
a an
d ve
geta
tive
stat
e, in
the
fron
tal m
uscl
e an
d in
the
expe
rimen
tal g
roup
.
1BA
3Su
n an
d C
hen
(201
5)In
terv
entio
nal-
cont
rolle
d cl
inic
al
trial
The
valu
e of
the
Gla
sgow
Com
a Sc
ale
incr
ease
d in
the
mus
ic g
roup
afte
r tre
atm
ent w
hen
com
pare
d to
the
cont
rol g
roup
. The
diff
eren
ce b
etw
een
the
two
grou
ps w
as si
gnifi
cant
(p <
0.0
5). T
he v
alue
of t
he q
uant
itativ
e el
ectro
ence
phal
ogra
m (E
EG) (
valu
e δ
+ θ/
α +
β) o
f the
mus
ic g
roup
dec
reas
ed
afte
r tre
atm
ent a
nd th
e di
ffere
nce
was
sign
ifica
nt in
com
paris
on w
ith th
e co
ntro
l gro
up (p
< 0
.05)
. The
y fo
und
that
mus
ic th
erap
y ha
s an
effe
ct o
n th
e pr
omot
ion
of re
cove
ring
cons
ciou
snes
s. Th
e qu
antit
ativ
e EE
G (δ
+ θ
/α +
β
valu
e) c
an b
e us
ed a
s an
obje
ctiv
e in
dex
to e
valu
ate
the
stat
e of
cer
ebra
l fu
nctio
n.
1BA
4H
eine
et a
l. (2
015)
Inte
rven
tiona
l-qu
asi e
xper
imen
tal
The
audi
tory
net
wor
k sh
owed
gre
ater
func
tiona
l con
nect
ivity
with
the
left
prec
entra
l gyr
us a
nd th
e le
ft do
rsol
ater
al p
re-f
ront
al c
orte
x du
ring
mus
ic,
com
pare
d to
the
cont
rol c
ondi
tion.
In a
dditi
on, t
he fu
nctio
nal c
onne
ctiv
ity
of th
e ex
tern
al n
etw
ork
impr
oved
dur
ing
the
mus
ic c
ondi
tion
at th
e te
mpo
ral-p
arie
tal j
unct
ion.
Alth
ough
it is
nec
essa
ry to
be
care
ful d
ue to
th
e sm
all s
ize
of th
e sa
mpl
e, th
ese
resu
lts s
ugge
st th
at e
xpos
ure
to fa
vorit
e m
usic
may
hav
e ef
fect
s on
the
audi
tory
net
wor
k of
pat
ient
s (im
plic
ated
in
the
perc
eptio
n of
rhyt
hmic
mus
ic) a
nd in
the
brai
n re
gion
s lin
ked
to
auto
biog
raph
ical
mem
ory.
1BA
5R
igan
ello
et a
l. (2
015)
Inte
rven
tiona
l-co
ntro
lled
clin
ical
tri
al
The
resu
lts sh
owed
that
the
inte
rnal
stru
ctur
e of
mus
ic (r
hyth
m, m
elod
y,
tone
s, se
mito
nes,
voic
e) c
an c
hang
e th
e au
tono
mic
resp
onse
in p
atie
nts w
ith
diso
rder
s of c
onsc
ious
ness
.
1BA
Sour
ce: A
utho
rs.
Cad. Bras. Ter. Ocup., São Carlos, v. 27, n. 4, p. 873-884, 2019
880880/884 Music therapy in patients with disorders of consciousness: an integrative review
Ord
erA
utho
r/ye
arT
ype
of s
tudy
Res
ults
/ C
oncl
usio
nLe
vel o
f ev
iden
ceD
egre
e of
re
ccom
men
datio
n6
Mag
ee e
t al.
(201
4)C
ross
-sec
tiona
lTh
e pr
otoc
ol th
at m
ainl
y us
es m
usic
al st
imul
i (M
ATA
DO
C) f
or e
valu
atio
n an
d tre
atm
ent o
f pat
ient
s with
DC
show
ed se
nsiti
vity
to m
easu
re a
udito
ry
resp
onsi
vene
ss a
nd in
tra re
liabi
lity.
1BA
7O
’Kel
ly e
t al.
(201
3)In
terv
entio
nal-
quas
i exp
erim
enta
lM
usic
ther
apy
prov
oke
a se
ries o
f res
pons
es in
dica
tive
of a
rous
al a
nd
sele
ctiv
e at
tent
ion.
Com
bine
d m
usic
ther
apy
and
neur
ophy
siol
ogic
al
eval
uatio
n co
uld
prov
ide
a di
stin
ct c
ontri
butio
n, re
veal
ing
an in
tact
resp
onse
to
pro
trudi
ng st
imul
i (ey
e an
d m
outh
mov
emen
ts, e
ye b
link)
, eve
n in
pat
ient
s in
veg
etat
ive
stat
e.
1BA
8R
aglio
et a
l. (2
014)
Obs
erva
tiona
lTh
e sy
stem
atic
obs
erva
tions
sho
wed
impr
ovem
ents
, esp
ecia
lly in
the
min
imal
ly c
onsc
ious
sta
te g
roup
(G1)
, in
som
e be
havi
ors
obse
rved
: eye
co
ntac
ts, s
mile
s, c
omm
unic
ativ
e us
e of
inst
rum
ents
/voi
ce, a
nd re
duct
ion
of ir
ritat
ion
and
expr
essi
ons
of s
uffe
ring.
In th
e ve
geta
tive
stat
e gr
oup
(G2)
, onl
y oc
ular
con
tact
s st
rong
ly in
crea
sed
durin
g tre
atm
ent.
1CA
9M
agee
et a
l. (2
016)
Long
itudi
nal
The
sele
ctio
n of
stim
uli w
ith e
mot
iona
l, au
tobi
ogra
phic
al o
r sel
f-co
rrel
ated
cha
ract
eris
tics
is fu
ndam
enta
l in
the
use
of m
usic
in p
eopl
e w
ith D
C
2BB
10C
astro
et a
l. (2
015)
Cro
ss-s
ectio
nal
The
cere
bral
resp
onse
to th
e pa
tient
’s fi
rst n
ame
was
mor
e fr
eque
nt in
the
mus
ic c
ondi
tion
than
in th
e co
ntro
l con
ditio
n. In
add
ition
, the
pre
senc
e or
ab
senc
e of
a d
iscr
imin
ativ
e re
spon
se in
the
mus
ic c
ondi
tion
seem
s to
be
asso
ciat
ed w
ith a
favo
rabl
e or
unf
avor
able
out
com
e, re
spec
tivel
y.
2CB
11Ve
rger
et a
l. (2
014)
Obs
erva
tiona
lTh
is n
ew p
roto
col s
ugge
sts
that
favo
rite
mus
ic h
as a
ben
efici
al e
ffec
t on
the
patie
nts’
cog
nitiv
e ab
ilitie
s. T
he re
sults
als
o su
gges
t tha
t bra
in p
last
icity
ca
n im
prov
e in
aut
obio
grap
hica
l con
text
s (e
mot
iona
l and
fam
ily).
The
sugg
estio
n is
to e
nlar
ge th
e fin
ding
s w
ith a
larg
er n
umbe
r of p
atie
nts
to v
alid
ate
the
hypo
thes
is o
f the
ben
efici
al e
ffec
t of m
usic
on
cogn
itive
re
cove
ry.
2CB
Sour
ce: A
utho
rs.
Tabl
e 2.
Con
tinue
d...
Cad. Bras. Ter. Ocup., São Carlos, v. 27, n. 4, p. 873-884, 2019
881881/884Santos, T. R. M. S.; Cavalcante, T. B.; Silva Junior, J. F.
Tabl
e 2.
Con
tinue
d...
Ord
erA
utho
r/ye
arT
ype
of s
tudy
Res
ults
/ C
oncl
usio
nLe
vel o
f ev
iden
ceD
egre
e of
re
ccom
men
datio
n12
Vogl
et a
l. (2
015)
Qua
litat
ive
Bra
in im
ages
suc
h as
PET
can
not s
uffic
ient
ly d
eter
min
e th
e im
pact
on
patie
nts’
’ liv
es. A
n ad
ditio
nal b
ehav
iora
l obs
erva
tion,
suc
h as
vid
eo
anal
ysis
, can
pro
vide
info
rmat
ion
abou
t a p
atie
nt’s
con
ditio
n. H
owev
er, i
t is
stat
ic a
nd in
flexi
ble,
as
it ca
ptur
es o
nly
a sh
ort p
erio
d. N
euro
anth
ropo
logy
ca
n he
lp to
clo
se th
is g
ap, r
eflec
ting
on th
e in
form
atio
n co
llect
ed in
the
patie
nt’s
env
ironm
ent,
whi
ch is
nec
essa
ry fo
r a c
aref
ul in
terp
reta
tion
of th
e da
ta.
4C
13A
brah
an, F
isch
er a
nd
Just
el (2
017)
Des
crpi
tive
It w
as p
ossi
ble
to h
ighl
ight
the
rele
vanc
e of
pat
ient
s’ re
lativ
es a
nd fr
iend
s’ co
llabo
ratio
n in
the
ther
apeu
tic p
roce
ss, p
rovi
ding
info
rmat
ion
and
poss
ible
re
sour
ces a
t all
leve
ls o
f aw
aren
ess,
for a
ther
apeu
tic p
roce
ss a
dequ
ate
eval
uatio
n an
d pl
anni
ng a
nd w
hen
the
prof
essi
onal
sele
cts t
he m
usic
, to
do it
ac
cord
ing
to th
e co
nditi
on, a
ge, g
ende
r and
mus
ical
bac
kgro
und
of th
e pa
tient
.
5D
14Sc
hnak
ers,
Mag
ee a
nd
Har
ris (2
016)
Des
crip
tive
The
resu
lts in
dica
ted
that
inte
rven
tions
with
mus
ic b
oth
base
line
and
post
-trea
tmen
t pro
voke
d hi
gher
-leve
l res
pons
es in
volv
ing
beha
vior
s tha
t de
mon
stra
te g
reat
er c
ompl
exity
, par
ticul
arly
in th
e au
dito
ry a
nd la
ngua
ge
dom
ains
. The
se re
sults
are
rele
vant
to c
ontri
bute
to th
e di
ffere
ntia
l dia
gnos
is
in p
atie
nts w
ith D
C.
5D
Sour
ce: A
utho
rs.
Cad. Bras. Ter. Ocup., São Carlos, v. 27, n. 4, p. 873-884, 2019
882882/884 Music therapy in patients with disorders of consciousness: an integrative review
between the central autonomous network structures and listening of music can play a relevant role in the use of music in patients with DC. Music therapy in coma patients due to traumatic brain injury (TBI) has an effect on the promotion of consciousness recovery. Quantitative electroencephalogram (EEG) can be an objective index to evaluate the state of cerebral function (SUN; CHEN, 2015).
Schnakers, Magee and Harris (2016) adds that music interventions can be modified according to the patient’s response “at the moment”. Protruding auditory stimuli, such as family voices, increase the probability of observing cerebral and behavioral responses in patients with DC. However, listening to music may offer a superior auditory stimulus, believed to involve key areas of consciousness support (primary and secondary auditory cortices).
Abrahan, Fischer and Justel (2017) confirms that it is possible to distinguish physiological changes in patients with music therapy interventions. These changes represent cerebral activation, increased attention and alert levels, which when receiving sensitive and sensory information acts as a filter, selecting some stimuli and discarding others. Thus generating a level of alert that predisposes to better capture the stimuli and generate appropriate responses to the environment.
4.2 Behavioral influence of music
The study of O’Kelly et al. (2013), which involved the behavioral assessments, provided greater accuracy in the diagnosis compared with the neuroimaging methods. This study indicated a series of significant responses in healthy individuals that correspond to arousal and attention in response to their favorite music, including simultaneous increase in breathing rate with globally improved EEG power. In addition, the behavioral data showed a significantly higher burst rate in the EEG for the favorite music within the vegetative state group.
Raglio et al. (2014) evidenced improvements in some behaviors observed, especially in the group in a state of minimal consciousness, such as eye contact, smiles, communicative use of instruments/voice, and reduction of irritation and expressions of suffering. In the vegetative state group, only eye contacts increased strongly during treatment. The observations showed a tendency of behavioral responses to sound-musical stimulation (improvement of communication and emotional expressions).
Vogl et al. (2015) believes that when it comes to conducting researches within a therapeutic environment with human interaction, as we do music
therapy, many relevant aspects occur at a subjective level that are difficult to illustrate in objective terms.
This author recognizes that neuroscience supports the understanding of the effect of musical therapy on the level of brain activity of people with DC. However, brain images such as PET cannot sufficiently determine the impact on patients’ lives. As a patient with DC cannot express themselves with the familiar means of communication, both neuroscience and behavioral observations represent a risk of misinterpretation.
Neuroanthropology can help to bridge this gap, reflecting on the information collected in the patient’s environment, which is necessary for a careful interpretation of the data. The author encourages the use of experiences, sensation, meaning and perception as relevant sources of knowledge, bringing together the different internal and external worlds of each individual involved and perceiving the relevance, not only of objective data, but also of the experience.
Puggina and Silva (2015) compared three groups (one control, one experimental message and one experimental music), and when considering all patients with DC, regardless of the etiology of unconsciousness, the music seemed to be a more intense stimulus. Both the music and the message provoked muscular tension in patients with disorder of consciousness rather than relaxation. However, specifically in the sedated patients, the music provided relaxation while the message produced tension.
Magee et al. (2016), in his study of 36 months, applied the evaluative methodology MATADOC (methodology developed in 17 years) with the objective to provide a rigorous and detailed evaluation of the auditory responsiveness in patients with DC. The music used varies between an unknown song and a familiar music with personal meaning to the patient. Besides the auditory modality, MATADOC also examines other behavioral domains. Magee concluded that MATADOC offers clinicians a useful measure to document behaviors consistently. According to Magee et al. (2017), MATADOC has greater sensitivity to evaluate the auditory responsiveness than other standardized assessments, suggesting that it is useful for the interdisciplinary assessment of consciousness in the DC to complete existing DC measurements.
5 Conclusion
O estudo conclui haver na literatura científica algumas evidências da eficiência e da eficácia da terapia musical no tratamento e avaliação de pessoas
Cad. Bras. Ter. Ocup., São Carlos, v. 27, n. 4, p. 873-884, 2019
883883/884Santos, T. R. M. S.; Cavalcante, T. B.; Silva Junior, J. F.
em coma, estados minimamente conscientes e estado vegetativo persistente, porém, são necessários mais estudos sobre níveis de intensidade aplicáveis da terapia musical e especificações do seu uso nos mais diversos contextos, a fim de subsidiar revisões sistemáticas para construção de protocolos e instrumentação para uso nos hospitais.
The very high heterogeneity of the studies selected in this review seems to complicate the immediate use of musical therapy in certain pathological conditions, however, as the disorders of consciousness, highlights research opportunities.
The study concludes there are in the scientific literature some evidences of the efficiency and efficacy of music therapy in the treatment and evaluation of people in coma, minimally conscious states and persistent vegetative state. However, more studies on applicable intensity levels of musical therapy and the specifications of its use in various contexts are important to subsidize systematic reviews for the construction of protocols and instrumentation for use in hospitals.
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Author’s Contributions Thanires Rafaele Menezes Soares dos Santos, Tamires Barradas Cavalcante and João Ferreira Silva Junior also contributed to the conception of the text. All authors approved the final version of the text.
