Giuseppe Scarso, researcher,
Alberto Ezzu, musictherapist

In this paper the Authors put forward some considerations concerning musical stimulation of coma patients.
They refer to methodology including the construction of musical sequences, the criteria of inclusion and exclusion of patients and the approach to the patient.
One clinical case is described with a discussion of the data observed.

Introduction
In the work presented here, the sound-musical stimulation of coma patients was conceived by starting from theoretical assumptions in the field of dynamic psychology with an Adlerian approach and from the theories and music therapy projects developed by Benenzon.
A coma is a modification of consciousness (in the field of psychology, consciousness is defined as "awareness of oneself and one’s surroundings") at a level which varies according to the severity and where the neurovegetative functions are more or less preserved.
Among the basic assumptions that support therapeutic interventions we recall the concept of plasticity of the CNS (Central Nervous System).
Having sustained damage the CNS, not being able to replace the neurons that die, effects their "repair" in such a way that new dendritic spines and new synapses are produced, therefore allowing the number of interneuronal connections to remain high. Another assumption sustains that the CNS’s capacity for attention depends on various factors, including the characteristics of the external stimuli to which it is subjected.
Furthermore, the CNS tends to elaborate sound- music stimuli more easily than non- structured acoustic stimuli (noise). A damaged CNS will the-re f o re derive more benefit from stimulation through a non-verbal language, that is, music. It also appears that musical stimulation improves cerebral blood vascularisation.
After Oppenheim-Gluckman it is assumed that in an unconscious condition (which is not necessarily synonymous with the absence of a mental life) a patient may be very close to his unconscious and, therefore, his mental activity is similar to that of dreams.

Objectives
The objectives proposed in this study are aimed at developing a methodology for music therapy interventions such to provide the patient and his family with the most suitable means to best endure the extremely difficult situation created by the clinical circumstances. More specifically, the procedure is: identifying an effective method; creating evaluation criteria for the effects; defining the eligibility of the patient; shortening the rehabilitation period and accelerating the recovery time; creating new communication channels and improving the existing ones between the patient, the team in charge and the family; decreasing the doses of pharmacological therapy.
We can aim to be able to be with the patient from his arrival in hospital to his discharge and in the phases of neuro-rehabilitation. From this perspective, music therapy is a process that accompanies all phases of hospitalisation and rehabilitation.
The treatment is carried out by a team, with discussion of clinical cases and with particular attention paid to the family, to relational- communicational aspects and to the patient even though he is in an unconscious state.

Method
In order that contact with the patient can be established and so that this contact is meaningful we decided to use:
1) music that is not well known and that has a general significance (GENERAL CASSETTE);
2) music known and appreciated by the patient (PERSONAL CASSETTE).
By "general significance" we mean instrumental, vocal and mixed musical compositions which recall meanings and symbols fundamental to Western culture and to its more recent and accepted adaptations to other cultures present in Italy.
In order to define the client’s musical and cultural tastes and to collect sound material suitable for optimising a personalized and focused stimulation model, the collaboration of family and friends is requested. They may even be asked to record their own voices while they talk, laugh and sing together: the effect of the mother’s voice on a newborn has been known for some time in the field of paediatrics and the effect that the voice of a family member or friend can have on us is just as well known. The fact that excessively rhythmic and anxiety- inducing music should not be part of the compilation is "common sense".
In order to decide whether the client is suitable for sound-musical stimulation, a clinical and neurological evaluation must be carried out beforehand, connected to an "empathetic" observation and instrumental tests: 1) electroencephalogram; 2) CAT scan; 3) evoked potential.
The research will be divided into a session of administration of the stimuli and the recording of basic physiological activity. A sound-music case- history file will be created for each patient. We will have to investigate the subjects’ sound-musical world with the aim of identifying its most significant aspects (the sound-music identity that Benenzon defines the ISO) in order to create the stimulus. Among the preceding tests the Evoked Potential will be used to establish whether the sound- music intervention can be perceived and to what extent.
The therapy is mainly aimed at young subjects with head injuries, but other pathologies are not excluded even at an older age. The exclusion criterion is linked to the presence of oedema, haematoma, open traumas or neurosurgical interventions.
We will seek to obtain a stimulus which evokes the greatest response from the Central Nervous System, where by greatest response we mean: a quantitative variation of the parameters observed; a greater number of parameters that vary; a greater extent of interest of the areas of the CNS; a longer duration of the effect created and observed.In a study on the effects of music therapy there are two technical aspects which should be treated with greater care: the manner of stimulation and the methods for collecting the data.
We should create the musical sequence so that the temporal succession of the pieces is consistent and linked to a communicative scheme. The volume of all of the pieces will have to be standardized so as not to create differences in perception which could be "aggressive" or anxiety - inducing simply because they are reproduced at different intensities. The re p roduction at the patient’s bedside will take place via a high quality CD player. The listening volume will have to be kept constant and suited to the patients hearing ability so that and modifications in the parameters cannot be attributed to a disturbance caused by excessive intensity.
The choice of measuring the vital signs which can be of the most use in evaluating the effects is very important. In intensive care the patient is continually monitored from a cardiovascular and respiratory point of view. Generally available at the patient’s bedside are: electrocardiograph, O2 saturation, number of respiratory actions per minute, systolic, diastolic and average pressure, and heart rate.

Statistical analysis method
The study carried out mainly makes use of graphical statistical investigation of the values gathered. For each series of average values calculated a graph was created in which the single values and the relative linear regression were highlighted. Linear re g ression is a statistical application which can prove to be very useful for identifying the tendency of a parameter to increase or decrease, defining the trend. This method is of particular benefit for brief music therapy programmes as it better emphasizes the gradual changes of the neurovegetative state.
Statistical analysis can be carried out by means of functions for comparing groups of data such as the t-test and the Analysis of Variance (ANOVA).
1) The t-test allows us to verify whether the difference between two groups is greater than that attributable to chance.
2) ANOVA measures the statistical significance of the variations in each group by comparing the levels of variability. More specifically, ANOVA is a parametric test that compares the effect of a single factor on the average of one or more groups.

Evaluation of the effects
The importance of the data gathered is shown by the dynamic characteristics of the neurovegetative conditions of the candidate during the sonorous stimulation compared to previous non-listening controls. Every variation caused by the music can be monitored and recorded with reference values. Furthermore comparison can indicate whether that variation is statistically significant.
In the study carried out we proposed to analyse the parameters both in the control situation (period before listening) and while listening to general and known music.
The comparison proposed aims to identify the variations to the patient’s basic state (control) related to listening and to investigate whether the known music can provoke qualitatively and quantitatively different effects to the general music. The comparison of control periods may also be of use to eliminate differences attributable to chance, while randomised controls over 24 hours give the controls a greater statistical significance.
The duration of the recorded periods both of listening and non-listening was 30 minutes.

Clinical case
As an illustration we present one of the cases of music therapy intervention carried out as the Intensive Care Teaching Division of the Molinette Hospital in Turin.
It is a case of a 21-year-old man, admitted to Intensive Care in 2000 following a critical head injury caused by a road accident. Upon arrival in Accidents & Emergency he was suffering from cardiac arrest and cerebral hypoxia.
The diagnosis upon arrival in the Anaesthesia and Intensive Care Unit was of head injury with Glasgow Coma Scale =3. Massive Facial CAT, Cerebral CAT and Spinal CAT were performed from which neither traumatic bone damage nor the presence of oedema or haematoma were observed. The EEG showed a graph with periods in which there was clear basic activity, an expression of important widespread electrical modifications.
The Raised Potential exam was more significant. We proceeded by studying the short latency responses. It was observed that, though the right- hand responses were normal, the left- hand responses were quite irregular. From the results obtained it was inferred that the patient had the necessary requisites to undergo music therapy stimulation.
In the meeting with the family it was made known that the subject does not have a specific musical culture and does not play any instruments.
He likes rock music of his generation (among the names: Ligabue, Queen, Cranberries) and he doesn’t demonstrate himself to be attracted by other types of music. At middle school he played the recorder, but this did not appear to give him much pleasure. The sound-music environment in which he lived was not very rich or particularly characteristic, or in any case the patient never expressed feelings, experiences or emotions connected to this type of stimuli.
From the meeting the need emerged to contact some of his friends to try to get to a sound- music stimulus closer to his actual tastes. The personalized compilation was thus realized with some difficulty and over some time. For various reasons, mainly to do with his conditions and the hospital’s requirements, the sound-music stimulation started about a month after is arrival in the Department and 12 listenings were performed using the GENERAL CASSETTE only. The PERSONAL CASSETTE was never administered as in the meantime the patient was transferred to the long- stay ward.

Conclusions
In the clinical case presented we can in any case highlight that the ratings of the physiological parameters measured during listening to music are at higher values compared to those recorded in the non-listening phase, even if this difference does not appear to be significant.
The number of re c o rdings was limited compared to other cases as the patient’s vital functions stabilized quickly and he was tra n s f e r red to a long-stay ward .
Even in the absence of a significant clinical improvement, we can observe that there is a difference between listening and non-listening. This confirms what has also been highlighted in other cases monitored with the same methodology.
First of all we can state that listening to music does not quantitatively modify the parameters measured in a significant way and, thus, there are no contraindications against its use in a clinical situation. However, variations are present which would indicate a response from the Central Nervous System, despite being injured, to an external stimulation and, thus, its capacity to understand and, somehow, to elaborate the stimulus.
The work carried out with this patient fundamentally allowed us to add and verify significant data to a music therapy protocol which was already following criteria and methods used in previous studies, thus identifying devices and new intervention possibilities to include in future research.
The involvement of consciousness as a biological process, the interaction of complex neural processes in auditory perception and the psychological, aesthetic and semantic aspects of music out-line the numerous research prospects in this field.
The preparation of a working method had to take all of these aspects into account in order to jointly define the objectives that are proposed.
The results obtained must be evaluated in the perspective of a pilot study in which above all we want to demonstrate the possibility to approach the coma through music with scientific investigative and analytical tools. As already discussed, the huge variability between the different clinical conditions of the patients in question makes it necessary to continue these studies in the future, adopting the means and the methods that have been identified. An unequivocal result was making the family’s participation in the sound stimulation active. This factor identifies the possibility of bringing the relatives of Intensive Care patients closer to the work of the medical staff, a situation which is not always possible due to the strict requirements of Intensive Care.
In conclusion, we can state that in the current phase of the study we need to investigate the individual clinical cases in a descriptive way before arriving at statistical analysis. Sound-musical stimulation demonstrates an effectiveness whose therapeutic value still remains to be seen.
The use of music therapy with coma patients seems to be an important clinical sphere that should be verified with more extensive case histories. The collection of these runs into difficulties represented by a certain resistance in the medical field to extend the rather "custodial" diagnostic protocols, reassuring for the clinician / doctor, despite the fact that, as is usually requested by the families, something more can be done, at least towards improving the patient’s "quality of life".

A coma is a modification of consciousness at a level which varies according to the severity and where the neurovegetative functions are more or less preserved.

Music therapy is a process that accompanies all phases of hospitalisation and rehabilitation.

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Scarso G., Rossi A., Mascia L., Urciuoli R.
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Urciuoli R., Scarso G.,
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