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Nordic Journal of Music Therapy

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Music therapy with disorders of

consciousness and neuroscience:
the need for dialogue
a b
Julian O'Kelly & Wendy L. Magee
a
Royal Hospital for Neuro-disability , Aalborg
University, Aalborg, Denmark, London , UK
b
Boyer College of Music and Dance, Temple
University , Philadelphia , USA
Published online: 20 Sep 2012.

To cite this article: Julian O'Kelly & Wendy L. Magee (2013) Music therapy with
disorders of consciousness and neuroscience: the need for dialogue, Nordic Journal of
Music Therapy, 22:2, 93-106, DOI: 10.1080/08098131.2012.709269

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 Nordic Journal of Music Therapy, 2013
Vol. 22, No. 2, 93–106, http://dx.doi.org/10.1080/08098131.2012.709269

RESEARCH ARTICLES
Music therapy with disorders of consciousness and neuroscience:
The need for dialogue
Julian O’Kellya* and Wendy L. Mageeb
a
Royal Hospital for Neuro-disability, London, UK and Aalborg University, Aalborg,
Denmark; bBoyer College of Music and Dance, Temple University, Philadelphia, USA
Downloaded by [Monash University Library] at 14:45 05 September 2013

(Received 7 March 2012; final version received 29 June 2012)

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 huma-
nist/music centred and behavioural/pragmatic influences. Whilst standar-
dised 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.
Keywords: music therapy; disorders of consciousness; neuroscience; low
awareness; brain injury

The purpose of this paper is to illustrate how current music therapy

approaches to the assessment and rehabilitation of those with disorders of
consciousness (DOC) would benefit from greater dialogue with the evolving
field of neuroscience, through an exploration of the transferrable lessons
available to clinicians and researchers.

*Corresponding author. Email: jokelly@rhn.org.uk

© 2013 The Grieg Academy Music Therapy Research Centre

 94 J. O’Kelly and W.L. Magee
DOC comprise a continuum of predominantly acquired conditions
characterised by altered states of consciousness. The term ‘‘low awareness
states’’ has been used synonymously in reference to this population
previously; however, current nomenclature favours the use of DOC.
DOC, as they are currently defined, primarily comprise two broad
categories: vegetative state (VS), where there are no discernible indications
of consciousness despite evidence of wakefulness (American Congress of
Rehabilitation Medicine, 1995; Giacino et al., 1997) and minimally
conscious state (MCS), where consciousness is limited (Giacino et al.,
1997; Giacino et al., 2002). The classification of ‘‘persistent vegetative state’’
(PVS) is advocated where individuals have been assessed as in VS for more
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than one year, given the perceived low probability of the recovery of
consciousness after this period (Giacino et al., 1997). Although coma is
categorised as a DOC, this paper does not include coma, i.e. where
consciousness and wakefulness are absent, in its discussion.
Accurately distinguishing between VS and MCS is crucial for decisions
regarding treatment, prognosis, resource allocation and medico-legal judg-
ments (Andrews, Murphy, Munday, & Littlewood, 1996; Giacino et al., 2002).
However, the assessment of people with DOC is a challenging clinical process,
highlighted by the suggested 37–43% rate of misdiagnosis in specialist units
(Andrews et al., 1996; Beaumont & Kenealy, 2005; Childs, Mercer, & Childs,
1993). This lack of clarity extends to epidemiological knowledge of the con-
ditions, with no reliable figures for MCS, and estimations of the prevalence of
VS lasting 6 months or more ranging between 5 and 25 per million of the
population in the UK (Beaumont & Kenealy, 2005).
The assessment of people with DOC is particularly complex because of
fluctuating arousal levels, lack of verbal comprehension and severe motor
disorders often rendering individuals completely immobile, without the means
of providing functional communication. Ascertaining the subtle differences
between responses that are reflexive and non-purposeful, and those that are
purposeful, is crucial in determining whether patients have an awareness of
their environment, although these are difficult to judge from behavioural
observation alone (Gill-Thwaites & Munday, 1999). Limbic responses may
also contribute to inaccurate assessment and misdiagnosis (Magee, 2007b).
Recommended best practice is for the use of several different assessment tools
to maximise sensitivity to the small and inconsistent responses typical of the
population, and that these tools should explore different responses to a range
of stimuli (Giacino et al., 2002).

Music therapy approaches to assessment and rehabilitation with disorders

of consciousness
In the field of DOC assessment and rehabilitation, music therapy has
evolved in the last 30 years within the wider approaches of sensory
 Nordic Journal of Music Therapy 95
stimulation and sensory regulation. Defining sensory stimulation for this
population is problematic as documented programmes vary considerably in
terms of intensity and nature (Lombardi, Taricco, De Tanti, Telaro, &
Liberati, 2002), advocating at the extreme 15–20 minutes of multisensoral
stimulation, 12–14 hours a day, 6 days per week (Doman, Dimancescu,
Wilkinson, & Pelligra, 1993). The concept of sensory regulation may be
traced to the influential critique of sensory stimulation programmes offered
by Wood (1991), who highlighted the need for stimulation programmes to
be carefully designed to promote optimum arousal levels for awareness and
attention, and to avoid habituation. Little evidence-based development of
this approach has occurred in the last 20 years since this leading guideline
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was published. Furthermore, two systematic reviews encompassing both

approaches have concluded that there was inadequate evidence to support
either of them (Lombardi et al., 2002; Rathnayake, 2009).
Boyle and Greer (1983) published the first study of music therapy with
this population, detailing the use of recordings of salient music to encourage
operant behaviour in VS. Using a single case design, this research examined
the effects of music (recorded) on learned behaviours (pressing a switch)
using operant conditioning (i.e. music as a reward). The study concluded that
‘‘operant assessment and treatment’’ using musical stimuli is indicated for
individuals as early as possible following injury (p. 3). The results not only
point to music being a motivating reward, but they also call into question the
capacity for people diagnosed as VS to demonstrate purposeful responses. It
may also be that diagnostic procedures since 1983 have refined to the extent
that the same patients nowadays may be diagnosed as MCS, not VS.
Since this landmark paper there has unfortunately been little in the way
of rigorous research or consensus to underpin the development of the
profession in this field. On the contrary, the existing literature reveals
divergent methodological approaches, different types of music advocated
(recorded, live, pre-composed or improvised) and contrasting models used
to interpret patient responses (behavioural, humanist, music centred and
psychoanalytic). Although there is some overlap within these approaches,
ontological differences suggest a distinction of two primary models:
humanist/music centred and behavioural/pragmatic.
The humanist/music-centred approach comprises an anthroposophically
informed model where melodic vocal improvisation is frequently advocated,
entrained with the physiological rhythms of the patient (i.e. respiration),
with a view to restoring the person into a less disordered state. The rationale
for this technique is based on the belief that breathing, as performed
through singing, is the fundament in the human condition and the major
agent in therapeutic recovery (Aldridge, 2001). However, there is little
literature detailing the use of standardised research methodologies or
protocols to support this approach. Papers detailing effects on heart rate,
respiration, EEG measures, voluntary movements and influences on the
 96 J. O’Kelly and W.L. Magee
regaining of consciousness (e.g. Aldridge, Gustorf, & Hannlich, 1990;
Gustorff, 1995) are lacking reference to measures used to eliminate bias or
rule out the changes occurring by chance, such as the use of controls or
randomisation. Interpretation of the research is made more difficult by the
use of terminology such as ‘‘post-coma’’ or ‘‘comatose states’’, whose
relevance to contemporary classification of VS/MCS is unclear. Protocols to
enable replication are absent. A notable exception in methodological rigour
(Formisano et al., 2001) incorporated blinded assessment with video
analysis and standardised assessment tools – the coma recovery scale
(CRS) (Giacino & Kalmar, 2006), and disability rating scale (DRS)
(Rappaport, Hall, Hopkins, Belleza, & Cope, 1982) to evaluate this music
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therapy approach with 34 people with DOC. Data drawn from the DRS
were inconclusive, however video observations suggested improvements in
‘‘psychomotor initiative’’ and decreases in psychomotor agitation.
In contrast, a handful of case description, research and clinical guideline
papers utilise behavioural techniques and share a positivist, outcome-
oriented approach, which may be characterised as the behavioural/pragmatic
model. Aside from contributions from a behavioural perspective (Boyle &
Greer, 1983; Boyle, 1994) a number of clinical guidelines have been
proposed that build a rationale for the work based on the findings from
neuroscience/neurological models (Baker & Tamplin, 2006; Magee, 2005)
and the social, motivational and emotional characteristics of music (Magee,
2005), highlighting the confounding aspect of limbic responses (Magee,
2007b). For example, Baker and Tamplin (2006) draw on guidelines for
sensory regulation techniques for DOC, detailed previously (Wood, 1991),
to advocate methods that use simple music, balancing ‘‘predictability’’ with
variations in dynamics, emphasising the ‘‘human’’ element of the work.
Much of the literature highlighted is lacking a clear delineation of
assessment, where clinicians focus their attention on evidence of awareness in
response to musical stimuli, and rehabilitation, where therapists support
patients in developing skills to optimise physical, psychological and social
function (Barnes & Radermacher, 2001). However, with respect to assess-
ment, a body of work is addressing the development and standardisation of an
assessment tool for use in music therapy with this population (Daveson,
Magee, Crewe, Beaumont, & Kenealy, 2007; Magee 2007a; Daveson, 2010;
Magee, Lenton-Smith, Siegert, Daveson, & O’Kelly, 2012a; Magee, Siegert,
Lenton-Smith, & Daveson, 2012b; O’Kelly & Magee, 2012), namely the
Music Therapy Assessment Tool for Awareness in Disorders of Conscious-
ness (MATADOC, formerly MATLAS, the Music Therapy Assessment Tool
for Low Awareness States). MATADOC evolved clinically over 14 years,
with the dual purpose of supporting the evaluation of music therapy
intervention and facilitating a diagnosis based on the five behavioural
domains commonly examined in assessment measures with this population
(auditory, visual, motor, arousal and communication) (Magee, 2007a). By
 Nordic Journal of Music Therapy 97
providing a standardised form of assessment, MATADOC holds potential for
future studies to address the lack of sensitivity of generic assessment tools to
the subtle effects of music therapy (Formisano et al., 2001).
Whilst assessment techniques are developing, there is a lack of evidence
to support music therapy in the rehabilitation of those with DOC, echoed by
a poor evidence base within the broader fields of sensory stimulation and
regulation. In particular, a greater understanding of the effects of the
various techniques advocated by music therapists in relation to arousal and
higher cortical functioning is required. The music therapy literature details a
range of methods and purported effects informed by ontologically
contrasting perspectives, however robust empirical studies are lacking.
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The literature regarding music therapy with DOC is being used as

‘‘evidence’’ whether that literature is from positivist or non-positivist
traditions. The central tenet of this paper aims to present an argument for
supporting the use of objective scientific principles to underpin music therapy
practice and research with DOC. Compared to the behavioural/pragmatic
model, the epistemological foundations of the humanist/music-centred
approach are less congruent with the positivist research paradigms advocated
by neuroscience; nonetheless, both approaches share a desire to develop
knowledge in this field, and all the techniques used are amenable to empirical
analysis. The following discussion of relevant discoveries from neuroscience
provides a context of evidence-based approaches, using standardised measures
and consensus nosology, which the authors encourage clinicians to incorporate
in their work to support the effective integration of music therapy in this field.

Lessons from neuroscience

The measurements of arousal and awareness are critical in music therapy
assessment of people with DOC. However, the current reliance on
behavioural observation alone lacks a comprehensive understanding of
how music affects arousal and awareness, in terms of the underlying
neurophysiological mechanisms involved. Neurophysiology, the evolving
branch of physiology dealing with the nervous system, provides a range of
measures to monitor arousal changes contingent to musical stimuli. Arousal
is a multidimensional concept, where physiological changes in blood
pressure, heart rate variability, skin conductance level and respiration relate
to activity in the sympathetic and parasympathetic branches of the
autonomic nervous system (ANS). Wijnen, Heutink, Van Boxtel, Eilander
and de Gelder (2006) present a cogent argument for focusing on ANS
measures of arousal in diagnostic work with DOC, given that arousal is
required to support interactions between cortical and sub-cortical systems
for consciousness to function. Their study of a DOC cohort’s responses to
sensory stimuli (i.e. auditory, visual, tactile and olfactory) determined a
correlation between ANS activity and positive recovery outcomes (Wijnen
 98 J. O’Kelly and W.L. Magee
et al., 2006). However, no detailed data were provided to identify any
differences in effects between each modality.
The evolving neuroscience of music provides a comprehensive overview of
the wide-ranging neurophysiological effects of music, primarily based on
studies of healthy individuals. Music is seen as speaking in ‘‘physiological
tongues’’ (Schneck & Berger, 2006, p. 138), bypassing cognitive processing to
speak directly to the ANS. Music has been demonstrated to affect a number of
physiological functions, for example changes in cerebral blood flow (Bernardi,
Porta, & Sleight, 2006; Blood & Zatorre, 2001; Evers, Dannert, Rödding,
Rötter, & Ringelstein, 1999), blood pressure (Bernardi et al., 2006; Khalfa,
Roy, Rainville, Dalla, & Peretz, 2008; Krumhansl, 1997), heart rate (Bernardi
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et al., 2006; Blood & Zatorre, 2001; Khalfa et al., 2008; Krumhansl, 1997;
Roy, Mailhot, Gosselin, Paquette, & Peretz, 2009), and respiration rate
changes (Bernardi et al., 2006; Blood & Zatorre, 2001; Khalfa et al., 2008;
Krumhansl, 1997). Listening to music causes widespread activity in the motor
and pre-motor cortices (Zatorre, Chen, & Penhune, 2007; Chen, Penhune, &
Zatorre, 2008), and in limbic and paralimbic cerebral structures thought to be
involved in reward/motivation, emotion and arousal (Blood & Zatorre, 2001;
Koelsch, 2005). This suggests music’s potential to affect emotional changes in
those incapable of verbal processing. Consequently, one might postulate
music therapy holds the potential to activate a range of cortical and sub-
cortical activity in DOC, dependant on which brain areas remain intact. For
example, if the amygdala and connectivity to related sensory pathways have
been preserved in a person with a DOC, some emotional processing may exist
in the absence of language processing and vocal or motor expressions of
emotion due to damage in other areas.
By stimulating cognitive, sensorimotor and emotional brain structures,
exposure to musical stimuli has important implications in relation to our
understanding of neuroplasticity. Neuroplasticity can be described as
changes within brain structures themselves as a result of stimulation or
where healthy brain regions compensate for damaged neighbouring areas,
taking on the functions for which those damaged areas were formerly
responsible. Animal studies (e.g. Ahissar, Abeles, Ahissarc, Haidarliua, &
Vaadiab, 1998; Johansson & Belichenko, 2002), studies with congenitally
blind or deaf humans (e.g. Bavelier et al., 2000, Röder et al., 1999) and more
recently musical training research (Panteva & Herholzb, 2011, Stewart et al.,
2003) indicate neuroplasticity is enhanced by sensory experiences and
enriched environments. Of particular relevance to this paper, several studies
using brain imaging techniques have tracked the effects of musical
experiences on brain plasticity in stroke rehabilitation to a high level of
temporal and spatial specificity. In their study using magneto encephalo-
graphy (MEG) methods, Särkämö et al. (2010) claim that music listening
after neural damage can support long-term changes in plasticity and
improve cognitive skills. Increases in the MEG measure of mismatch
 Nordic Journal of Music Therapy 99
negativity (relating to cortical sensitivity to violations of expected auditory
patterns) correlated with improvements on word recall and mental test
results. Furthermore, studies indicate that neural reorganisation in the
sensorimotor cortex following stroke results from ‘‘music-based therapy’’ as
revealed through functional magnetic resonance imaging (fMRI) methods
(Rojo et al., 2011). Schlaug, Norton, Marchina, Zipse, & Wan (2010) also
demonstrated changes to brain structures in a fMRI study of the effects of
melodic intonation therapy following brain lesions, where there was a visible
increase in the size and length of fibres in the arcuate fasciculus, an area of
the brain connecting cortical regions important in language processing
(Phillips et al., 2010).
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The extent to which plasticity may occur with DOC populations is

unclear, although plasticity has been hypothesised in a few reported cases of
pharmacological interventions inducing recovery of consciousness (Pistoia,
Govoni, Fini, & Sara, 2010), and where central thalamic deep-brain
stimulation has encouraged cognitively mediated behaviours (Shah & Schiff,
2010). However, despite a review paper advocating music therapy for
promoting neuroplasticity (Baker & Roth, 2004) there has been little follow
up in this line of enquiry within the profession relevant to work with DOC.
Further important messages for music therapists are provided by the
contrasting perspectives available in the neuroscience literature on auditory
processing with DOC. A number of papers are informed by studies using
positron emission tomography (PET) and fMRI methods. Frequently, these
studies report a demarcation of auditory responses between MCS and VS,
demonstrating, for example, greater functional connectivity between the
secondary auditory cortex and temporal and prefrontal association cortices
in MCS compared to VS (Boly et al., 2004), explaining how people in MCS
may perform better in response to auditory information than those in VS.
Studies highlight residual cortical activity in VS patients, but suggest that this
occurs only in isolated cortical activity or ‘‘cortical islands’’ (Menon et al.,
1998) and is restricted to a ‘‘low level’’ without ‘‘higher-order’’ integration,
considered necessary for conscious perception (Laureys, Perrin, Schnakers,
Boly, & Majerus 2005). Significantly, such studies have also enabled people
with DOC to demonstrate wilful or voluntary responses to auditory stimuli,
without the need for observed behavioural responses such as speech or
movement, suggesting conscious functioning in some people erroneously
diagnosed as VS (Monti et al., 2010; Owen, Schiff, & Laureys, 2009).
In contrast, more positive suggestions as to the sophistication of cortical
processing in VS are available, illustrating the need for an open mind on the
capacity for sensory perception in VS, and consequently the wider field of
awareness and consciousness in this population. Early behavioural research
revealed different ‘‘arousal profiles’’ for people in VS, highlighting a range of
responsiveness from ‘‘eyes shut and no body movement’’ through to ‘‘engaged
in activity’’ (e.g. scratching) and ‘‘vocalisation’’ both before and after
 100 J. O’Kelly and W.L. Magee
multi-modal and uni-modal stimulation treatment (Wilson, Brock, Powell,
Thwaites, & Elliott, 1996, p. 106). Schiff et al. (2002) undertook PET/fMRI
analysis of five people in VS receiving sensory stimulation. The results showed
that each person expressed a unique pattern of responses, including ‘‘correlate
areas of intact brain metabolism with fleeting displays of purposeful
behaviour’’ (p. 1210) in three cases, suggesting the retention of partial function
despite widespread damage to other areas. Using EEG methods, Kotchoubey
et al. (2005), suggested the likelihood of purely behavioural assessment of VS
being biased towards an under-estimation of patients intact information
processing abilities. In a study including 50 PVS subjects, they evidenced the
existence of a sub-population of PVS patients with preserved connectivity
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between the thalamus and higher-functioning areas in the cortex.

Habituation reactions observed in people in VS who are presented with
repetitive auditory stimuli suggest evidence of learning in VS, possibly at a
cortical level even if not in a fully processed manner (Kotchoubey et al.,
2006). This provides comparable findings to those of Boyle and Greer (1983)
in relation to musical stimuli published over two decades earlier, high-
lighting the potential for both positive and negative effects of different
auditory environments for this population.
The neurophysiological assessment techniques covered in this section are
not without considerable logistical and cost implications. However, in the
first instance, the use of EEG methods offers an appropriate starting point
to explore subtle neurological responses to music therapy in real time. These
methods are now relatively inexpensive, simple to use and non-invasive
compared with other imaging methods. The risk and cost of EEG
procedures can be argued in relation to the rewards these methods can
reap. Furthermore, where neuro-rehabilitation units incorporate EEG in the
routine assessment of patients admitted, the equipment and technical
support required may be accessible to music therapists well integrated within
the multi-disciplinary team.

Music therapy with disorders of consciousness: the way forward

From reviewing the literature it is apparent that individuals with DOC
respond differentially to a range of musical stimuli in assessment and
rehabilitation programmes. The literature points to two ontologically
distinct approaches as effective in gaining a range of responses from people
with DOC, but rigorous supporting evidence is lacking, as is the case for
sensory stimulation and regulation programmes generally. Advances in
behavioural assessment measures specific to music therapy may soon assist
in developing research into the benefits of musical stimulation for this
population (Magee et al., 2012a, b & c).
Our understanding of neurophysiological responses to music within
normal populations indicates the promotion of wide-ranging cortical
 Nordic Journal of Music Therapy 101
activity, lending support to the potential of music therapy to stimulate intact
areas in the most severely brain damaged individuals. From neuroscience we
are also provided with evidence of musical experiences promoting
neuroplasticity and functional gains following cerebral lesions, but not as
yet with the DOC population. Despite differences in opinion amongst
experts as to the functional capacity of people diagnosed with DOC (in
particular VS), it is clear that neurophysiologic assessment of the population
is indicated for those whose diagnosis is difficult to ascertain by behavioural
assessment alone.
It is noteworthy that the above neurophysiological studies using
‘‘auditory stimuli’’ have so far avoided any sustained focus on music as
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the stimulus of choice, be it live or pre-recorded, despite a body of evidence

indicating the wide-ranging effects of music on arousal and awareness.
Music therapy and neuroscience collaborations offer exciting possibilities
for both parties in revealing what ‘‘covert’’ responses to music therapy might
exist for people with DOC, thus far undetected by behavioural observation
alone. This shared focus may enhance assessment techniques by observing
immediate responses to musical stimuli, and determine whether music
therapy might support neuroplasticity over time, as suggested by
rehabilitation studies with higher-functioning brain-damaged individuals.
This paper has highlighted how the neuroscience literature supports the
use of music with DOC populations. It is important that music therapy
clinicians and trainers, regardless of epistemological alignment, capitalise
on this by integrating the neuroscience knowledge base into their
arguments for using music therapy with DOC. This will serve to equip
therapists with a language and knowledge that are demanded in the clinical
arena.
For music therapy to become firmly established within modern DOC
assessment and rehabilitation programmes, an overarching question needs
to be addressed: can the rationale for this work be supported by direct
scientific evidence? The multitude of variables involved in music therapy
(e.g. type of music, how music is performed, the approach of the therapist,
etc.), combined with its use with a clinically heterogeneous population, pose
significant challenges for undertaking replicable, standardised research.
However, standardised diagnostic criteria, assessment tools (both musical
and global) and sophisticated neurophysiological assessment methods such
as EEG are available to assist in this endeavour. By taking advantage of
these resources, the methodological failings and evidence gaps in the
literature may be addressed systematically in order to properly assess the
effects of music therapy on arousal, awareness and plasticity in this
population. The time has come for music therapists to expose their clinical
skill and methods to objective empirical analysis to underscore the
development of the profession and evidence-based methods in music
therapy with DOC.
 102 J. O’Kelly and W.L. Magee

Acknowledgements
The authors would like to acknowledge the support of Dr Sophie Duport, Head of
Research at the Royal Hospital for Neuro-disability, and funding from Aalborg
University, the Neuro-disability Research Trust and the Music Therapy Charity.

Notes on the contributors

Julian O’Kelly, MSc, Dip MT, is currently undertaking a PhD Mobility
Fellowship with Aalborg University in association with the Royal Hospital
for Neuro-disability. His current research is exploring the neurophysiolo-
gical effects of music therapy with those with DOC.
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Wendy L. Magee is Associate Professor, Music Therapy Program, Boyer

College of Music and Dance, Temple University, Philadelphia, PA and
external supervisor, Doctoral Programme in Music Therapy, Aalborg
University.

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