Marissa Emple, MA, LCAT, MT-BC

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.  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. 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.  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.  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.  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. Minimally Conscious State (MCS)
Persistent Vegetative State (PVS
or VS)
Coma
Brain Death
Moyer, 2012

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. 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.  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.  “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.  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.  Traumatic Injury
 Non-traumatic injury
 Degenerative and metabolic disorders
 Developmental malformations

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.  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. Long-term care
Rehabilitation
Palliative Care
End-of-Life Care

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. 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.  Musical parameters of verbal
communication
o Pitch, dynamics, melodic
contour, articulation, timing,
phrasing
 Neuroplasticity
 Cross-Cultural social medium
 Organization
 Emotional response

20. “Music is not just what it is, but is that which it means to the
people.” – Simon Rattle, 2004

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

23.  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

24.  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

25.  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

26.  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)

27.  Client-directed
o Assess for signs of
engagement or over-
stimulation
 Sequence stimuli
o auditory, vibroacoustic,
vestibular or kinesthetic,
visual
• Progressively
increasing complexity

28.  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

29.  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

30.  Implications for co-
treatment
o Physical therapy
• Decrease in muscle tone
• Increase range of motion
• Promote self-initiated
movement
• Improved breath control

31.  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

33.  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.

35.  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

36.  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

37.  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

39.  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

41. 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.

42. 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.