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The Creative Use of Music Therapy for the Pediatric Long-Term Brain Injury Patient


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Marissa Emple, MA, LCAT, MT-BC

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The Creative Use of Music Therapy for the Pediatric Long-Term Brain Injury Patient

  1. 1.   Marissa G. Emple, MA, LCAT, MT-BC Licensed Creative Arts Therapist Music Therapist – Board Certified Clinical Training Coordinator Elizabeth Seton Pediatric Center Yonkers, NY Brain Injury Alliance of New Jersey Annual Seminar May 12, 2016
  2. 2.  To gain a basic understanding of music therapy  To gain a basic understanding of disorders of consciousness o To differentiate between persistent vegetative and minimally conscious states  To expand awareness of current music therapy research with DOC patients  To explore music therapy assessment and treatment approaches and techniques for pediatric patients who present with DOC  To stimulate ethical thinking related to treating patients with DOC  To provide concrete ideas for co-treatment with rehabilitation therapists  To bring awareness of age-specific limitations to treating pediatric DOC patients  To recognize the depth and scope of music therapy treatment for the pediatric patient within a holistic, client-centered model
  3. 3. Music Therapy is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program. (American Music Therapy Association, 2013)
  4. 4.  Infants, children, and adults with issues related to the following: o Developmental and learning disabilities o Mental Illness • Post-traumatic stress disorder, bi-polar spectrum disorders, anxiety disorder, schizophrenia, personality disorders, clinical syndromes, suicide ideation and self-mutilation, eating disorders, psychosexual/gender dysphoria; ADHD; etc. o Substance abuse problems o Acquired and traumatic brain injury o Physical disabilities o Acute and chronic medical illness o Acute and chronic pain o Standard and complicated childbirth o Neurological devastation o Neurological disorders, such as Parkinson’s and Huntington’s Diseases o Healthcare worker “burn-out” and compassion fatigue o Anticipatory grief and bereavement (individual and family) o Active dying o Premature infants o Imprisonment (inmates requiring rehabilitation; example: sex offenders/addicts)
  5. 5.  Acute Care Medical hospitals o Labor & Delivery o Neonatal intensive care unity (NICU) o Pediatric intensive care unit (PICU) o Post-Anesthesia Care Unit (PACU) o General Pediatrics o Hematology/Oncology o Emergency Department o Hospice & Palliative Care o General Medical-Surgical o Post-surgical o Dialysis  Psychiatric hospitals  Partial hospitalization programs  Colleges/Universities  Hospice Centers  Drug/Alcohol rehabilitation centers  Community mental health clinics  Correctional facilities  Halfway houses  Schools  Agencies serving persons with developmental disabilities  Outpatient clinics  Nursing homes  Physical rehabilitation centers  Private practice
  6. 6.  Academic degree in music therapy from a college or university that is accredited by the AMTA and CBMT  1200 supervised clinical training hours at an accredited site for MT-BC  LCAT Limited Permit and an additional 1500 clinical contact hours with weekly supervision with a qualified supervisor at an accredited site to earn LCAT MT-BC: Music Therapist – Board Certified This credential is granted by the Certification Board for Music Therapists to identify music therapists who have demonstrated the knowledge, skills and abilities necessary to practice at the current level of the profession. The CBMT is fully accredited by the National Commission for Certifying Agencies. Continuing education, including ethics LCAT: Licensed Creative Arts Therapist This is the New York State licensure, granted by the NY State Office of the Professions, required for dance/movement therapists, drama therapists, music therapists, and art therapists to assess and diagnose mental health disorders, and practice psychotherapy.
  7. 7. Minimally Conscious State (MCS) Persistent Vegetative State (PVS or VS) Coma Brain Death Moyer, 2012
  8. 8. Controversial o Pejorative, refers to patients as being vegetable- like Remains the legal nomenclature for now “Unresponsive Wakefulness Syndrome” o Humanity, dignity, hope O’Kelly, et al., 2013
  9. 9. Persistent Vegetative State • No evidence of awareness of self or environment • No evidence of sustained, reproducible, purposeful, or voluntary behavioral responses • No evidence of language expression or comprehension Minimally Conscious State • Limited awareness of self or environment • Limited behavioral responses • Limited language expression and/or comprehension Persistent Vegetative State (PVS) and Minimally Conscious State (MCS) • Present sleep/wake cycles • Preservation of autonomic and hypothalamic function • Bowel/Bladder incontinence • Variable preservation of cranial nerve and spinal reflexes
  10. 10.  Glasgow Coma Scale (GCS)  JFK Coma Recovery Scale – Revised (CRS-R)  FOUR score  Post-Acute Level of Consciousness (PALOC)  Glasgow Outcome Scale – Extended (GOSE)  Disability Rating Scale (DRS)  Rappaport Coma/Near Coma Scale
  11. 11.  “Prevalence of MCS in children under the age of 18 is estimated to be between 44 and 110 per 100,000 children, based on U.S. census data from 2000, when the overall population of children in the U.S. was 72,293,812” (Magee et al., 2015)  Glasgow Coma Scale  Coma Recovery Scale Magee, et al., 2015
  12. 12.  Require intact auditory system  Assume a prior mastery of language skills  Require a certain level of motor functioning ability  Lack of inter-observer reliability  Cannot distinguish “Locked-In State”
  13. 13.  Traumatic Injury  Non-traumatic injury  Degenerative and metabolic disorders  Developmental malformations
  14. 14.  Is a person in PVS a “person” (in a number of senses) (Gormally, 1993)?  Can a person in PVS have interests, or “best interests” (McLean, 2001)?  Should scarce medical resources be allocated to people in PVS?  Are nutrition and hydration for a person in PVS medical operations?  Is there a difference between killing a person in PVS and letting him or her die (Randall, 1997)?  Should people in PVS be considered to be “dead” (in a number of senses)?
  15. 15.  Ethics and the Rehabilitation of Persons with Disorders of Consciousness o “Is rehabilitation well-intentioned hand-holding while natural recovery takes place?” o Allocation of healthcare dollars  Ethics of Music Therapy and Disorders of Consciousness o Palliative Care is humanistic and holistic o Existential challenges • Interpersonal and intrapersonal
  16. 16. Long-term care Rehabilitation Palliative Care End-of-Life Care
  17. 17. “In the tradition of St. Elizabeth Seton, we cherish all children and believe in the healing power of loving relationships. As a center of pediatric rehabilitative and palliative care, we are inspired by her legacy as we join with families in the holistic care of their children.”
  18. 18. Traumatic Brain Injury Non-Traumatic Brain Injury  Non-Accidental Traumatic Brain Injury Central nervous system degenerative and neurometabolic disorders Congenital anomalies and genetic disorders Complications of prematurity
  19. 19.  Musical parameters of verbal communication o Pitch, dynamics, melodic contour, articulation, timing, phrasing  Neuroplasticity  Cross-Cultural social medium  Organization  Emotional response
  20. 20. “Music is not just what it is, but is that which it means to the people.” – Simon Rattle, 2004
  21. 21.  Music Therapy Assessment Tool for Awareness of Disorders Of Consciousness  Principle Subscale: motor, communication, arousal, visual, and auditory domains o Good interrater reliability (mean = 0.83, SD = 0.11), good test– retest reliability (mean = 0.82, SD = 0.05), with good internal consistency (α = 0.76) o Performance against another validated sensory assessment as an external reference standard found excellent agreement (100%) for diagnostic outcomes of awareness states Magee et al., 2015
  22. 22.  Compared MATADOC to 3 external reference standards  Diagnostic outcomes were in agreement in 3 cases  4th case provided a diagnosis of a higher awareness state than the external reference standards  MATADOC items provided similar ratings for responsiveness with 3 exceptions Magee et al., 2015
  23. 23.  MATADOC appears to have clinical utility for use with pediatric PDOC.  MATADOC provides a useful tool for ongoing evaluation of progress for children with PDOC  It may provide a sensitive measure of responsiveness to sensory stimuli; however, further testing is required to validate it for pediatric PDOC.  Early indications suggest that it may contribute to differential diagnosis for children with PDOC.  Both the measure and the protocol need refinement to make it relevant for pediatric PDOC. Magee et al., 2015
  24. 24.  Increase arousal without overstimulation  Increase tolerance of sensory input without stress behaviors  Promote sustained, reproducible, purposeful, or voluntary responses to sound or vibroacoustic stimuli  Provide context for human connection through sound, vibration, and touch
  25. 25.  ATVV Sequence (Burns et al., 1994) o Developed for premature infants o Auditory (infant-directed talk), tactile (massage), vestibular (rocking); visual throughout (eye contact) o Enables responsiveness while avoiding overstimulation  Purposeful sequence of stimuli presentation: o Auditory o Tactile o Vestibular o Visual  Music and Multimodal Stimulation – adaptation of Auditory/Tactile/Vestibular/Visual (Standley, 1998; 2010)
  26. 26.  Client-directed o Assess for signs of engagement or over- stimulation  Sequence stimuli o auditory, vibroacoustic, vestibular or kinesthetic, visual • Progressively increasing complexity
  27. 27.  Auditory o Voice alone (humming) or o Drone (e.g., shruti box) o Layer (add voice or drone)  Vibroacoustic o Soundwave Chair or bass resonator bar  Kinesthetic o Passive range of motion (PT)  Visual o Eye contact or mirror
  28. 28.  Localized vibroacoustic stimulation to specific parts of body o Bass resonator bar with soft mallet  Purpose o Direct attention to different parts of body o Promote awareness of self o Encourage clear, purposeful responses to vocal and verbal cues  Can incorporate principles of entrainment
  29. 29.  Implications for co- treatment o Physical therapy • Decrease in muscle tone • Increase range of motion • Promote self-initiated movement • Improved breath control
  30. 30.  Physical Therapy & Occupational Therapy o Therapy Ball • Vestibular input  increased arousal o Soundwave Chair • PROM • Sitting • Proprioception  Speech Therapy o The voice • Purposeful vocalization • Reciprocal vocalization o Passy-Muir Valve (PMV) • Vocalization • Decreased anxiety  Tolerance of PMV
  31. 31.  MKT: live music combined with physical stimulation for short, intensive bursts o Increased arousal o Responsiveness to commands o Purposeful, functional movement and communication Noda, R., Maeda, Y., Yoshino, A. (2004). Therapeutic time window for musicokinetic therapy in a persistent vegetative state after severe brain damage. Brain Injury, 18(5), 509-515.
  32. 32.  Traumatic brain injury, secondary to motor vehicle accident o Subsequent craniectomy and cranioplasty; facial and femur fractures; spasticity; seizures; s/p G-tube placement, chronic lung disease, asthma, cortical blindness, L cranial nerve palsy o Spanish-speaking immigrant parents o 3 younger siblings  PVS
  33. 33.  Music therapy goals: o Increase tolerance for multi-modal input o Increase awareness of self and environment o Family/sibling bonding o Achieve highest quality of life  Music therapy interventions: o Co-treatment with physical therapy on Soundwave Chair o Co-treatment with speech therapist, utilizing Passy-Muir speaking valve o Songwriting with siblings and parents o Improvisation-based individual music therapy techniques
  34. 34.  Non-Accidental traumatic brain injury at age 2.5 years o skull fracture; subdural hematoma; cerebral infarcts; autonomic dysfunction; seizure d/o; spasticity; GERD; dysphagia; s/p g-tube placement  MCS  Family only speaks Mandarin  Family-Centered Therapy o Recordings of Love with father and brother  Individual music therapy
  35. 35.  The needs of the pediatric brain injury patient vary from those of adults due to difference in developmental levels/nature of injury.  Co-treatment with rehabilitation therapists provides an important context for an interdisciplinary team approach.  Within a therapeutic relationship, music therapy supports healing for the family of a pediatric DOC patient within a humanistic, holistic treatment model.  There is a need for further research related to music therapy assessment and treatment planning for pediatric DOC patients. o MATADOC may become a validated assessment tool for pediatric DOC patients
  36. 36. Burns, K., Cunningham, N., White-Traut, R., Silvestri, J., & Nelson, M. (1994). Infant stimulation: Modification of an intervention based on physiologic and behavioral cues. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 23(7), 581-589. Elliott, L., & Walker, L. (2005). Rehabilitation interventions for vegetative and minimally conscious patients. Neuropsychological Rehabilitation, 15(3/4), 480- 493. Gill-Thwaites, H., & Munday, R. (2004). The sensory modality assessment and rehabilitation technique (SMART): A valid and reliable assessment for vegetative state and minimally conscious state patients. Brain Injury, 18(12), 1255-1269. Keller, I., Hülsdunk, A. & Müller, F. (2007). The influence of acoustic and tactile stimulation on vegetative parameters and EEG in persistent vegetative state. Functional Neurology, 22(3), 159-163. Lombardi, F., Taricco, M., De Tanti, A. Telaro E., & Liberati, A. (2002). Sensory stimulation for brain injured individuals in coma or vegetative state. Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD001427. Magee, W.L. (2005). Music therapy with patients in low awareness states: Approaches to assessment and treatment in multidisciplinary care. Neuropsychological Rehabilitation, 15(3/4), 523-536.
  37. 37. Magee, W.L., Ghetti, C.M., Moyer, A. (2015). Feasibility of the music therapy assessment tool for disorders of consciousness (MATADOC) with pediatric populations. Frontiers in Psychology, 6, 1-12. Magee, W.L. (2007). Development of a music therapy assessment tool for patients in low awareness states. NeuroRehabilitation, 22, 319-324. Noda, R., Maeda, Y., Yoshino, A. (204). Therapeutic time window for musicokinetic therapy in a persistent vegetative state after severe brain damage. Brain Injury, 18(5), 509-515. Standley, J. (1998). The effect of music and multimodal stimulation on physiologic and developmental response of premature infants in neonatal intensive care. Pediatric Nursing, 24(6), 532-538. Standley, J. & Walworth, D. (2010). Music therapy with premature infants: Research and developmental interventions (2nd ed.). Silver Spring, MD: AMTA. Wood, R. (1991). Critical analysis of the concept of sensory stimulation for patients in vegetative states. Brain Injury, 4, 401-410.