Music Therapy in Vegetative State

 

In medicine, the terms vegetative state, unresponsive wakefulness syndromeand minimally conscious state (also coma vigile, Apallisches Syndrom and Wachkoma) are used to define one of the most serious neurological syndromes. These patients are seen as unable to perceive, and communication with, their environment. Vegetative state and awareness are mutually exclusive according to the medical tradition. Despite intensive discussions of the term consciousness, the general and uncontroversial view in medicine appears to be that brain function determines consciousness.

 

In Germany, Kretschmer (1940) and Gerstenbrand (1967) were the first to describe case studies of a disease with failure of all cerebral functions and alowered level of cerebral functions to the midbrain level with disinhibition symptoms. They called it a transitional syndrome that may disappear either completely or almost completely. Gerstenbrand described the condition in more detail, from its onset, progress, fully developed state up to the remission phases. Jennett and Plum (1972) described an analogous condition and called it ‘persistent vegetative state’, and they added to the title ‘a syndrome in search of a name’. Giacinoand Zasler (1995) gave a description of patients, who have regained very limited conscious responses and called it 'minimally conscious state'. In 2003 it was defined by Brain Injury Association of America as the term used for a severe traumatic brain injury in which a person is no longer in a coma or a vegetative state.

 

I don’t agree in this definition as a new form of brain disease! Since 1967 this state was characterised by Gerstenbrand and others as a remissionphase of vegetative state. So observations made by nursing staff, relatives, therapists and physicians led to worldwide discussions of these terms. In German Wachkoma (literally: ‘awake-coma’) summarizes the discrepancy of such observations between recognizable sleep–alert phases and seeming inability to enter into contact.

 

In 2004 Owen (Cambridge, England / since 2011 Ottawa, Canada) and Laureys (Liege, Belgium) describe recent studies with fMRT. They can show signs of consciousness in people who were attributed to the vegetative state. In 2011, the researchgroup in Belgium replaced the term vegetative state by the term unresponsive wakefulness syndrome.

 

Vegetative state is mostly caused by brain damage due to severe craniocerebral injury trauma, cerebral haemorrhage, or hypoxia. Advances in rehabilitative medicine and emergency care facilitate successful reanimation and treatment in a growing number of patients. They survive such acute events, and are even fully rehabilitated in most cases. Some, however, remain in apermanent state of coma vigile. All descriptions of the state assume a functional failure of the cerebral cortex and complete loss of cognitive potentials while brainstem functions are maintained. There are various descriptions of a possible remission, and all assume that recovery cannot be expected after a period of more than 12 months in this condition.

 

On my qualitative research of music therapy with these patients an access to these people and references to the existence of their consciousness could, however, be found (doctoralthesis, Chair of Clinical Research Methods, Prof. Dr. David Aldridge, Faculty of Medicine, University of Witten-Herdecke). Participants in this study were between 20 and 50 years of age and had been in the described state for at least 18 months and as longs as seven years. All therapy possibilities were considered as exhausted. The patients live in a long-term nursing institution for adult residents with severe neurological handicaps (Haus Königsborn, Lebenszentrum Königsborn / Unna, Germany).

 

Summary

 

In this study medical knowledge on long-term phases of vegetative state (minimally conscious state) turns out to be full of gaps, and many prognoses are wrong. Prior to a discussion on definition and terminology of vegetative state, the phenomen on itself urgently requires new scientific research. Such research must focus not only on the acute situation of patients or the first months after the event, but fore most on the long-term phase in order to close the tremendous gaps in knowledge.

 

A first objective would be to update knowledge on the illness and its progress, diagnosis and treatment in order to gain new scientific findings. The perspective must then be expanded beyond the acutestage and the first few months, and data must be collected on long-term development and the condition of patients in vegetative state. The subject of this study is not the abstract illness of a patient but the entire human being himself or herself. This is why in such a research project the search for biomedical findings and concepts of relational medicine must not be mutually exclusive, but must complement each other. Only a combination of both allows us to collect comprehensive data on the illness and the patients affected, and in addition on consciousness as the core of human existence.

 

Accordingly, an evaluation must focus equally on the search for high efficiency in therapy and care, and on the quality of life for patients in vegetative state. Such an evaluation must be free from the pressure of expectations from medicine and society on cost reduction in treatment and care, and also free from economic interests. We may assume that the ideas presented in this study will be confirmed by such scientific research. Medicine would thus provide new descriptions of patients in vegetative state, and thereby encourage society to recognize these patients as living persons with a consciousness the depth of which is hard to evaluate.

 

Opinions on patients in vegetative state are divided. There are open discussions on the value of life in such patients, their right to live and be taken care of by society.

 

This study tried to demonstrate that patients in vegetative state are people with serious brain damage, but also with aconsciousness who in their specific form of life have the capacity to meet others or be met in an encounter, and who have the same basic rights as everybody else.

 

Our society must address the legal and ethical implications. Society is challenged to ensure the rights of patients in vegetative state to a protected life and physical integrity. The right to physical integrity implies the right to medical and nursing care. The aspects involved here are more ethical than legal in nature. Patients in vegetativestate are not in confrontation with society, but one of its parts. As a consequence of their impairments, they are among the weakest elements and in need of support. Any discrimination and the worldwide debate on the value oftheir lives as a cost–benefit calculation, or possible euthanasia, are in sharp contrast to the findings of this study, ethically unjustifiable and thoroughly reprehensible.

 

Today
 
In recent years the results of this study were further deepened. I developed the approach of music therapy with people in unresponsive wakefulness syndrome and minimally conscious state. It is not only confirmed but is regularly modified on the basis of now more than 20000 treatments.

 

more information

 
Herkenrath, A. (2005a). Encounter with the Conscious Being of People in Persistent Vegetative State. In: Aldridge, D. (Hrsg.) (2005). Music Therapy and Neurological Rehabilitation: Performing Health. S. 139-160. London, J. KingsleyPublishers.
ISBN 1-84310-302-8.
www.jkp.com/catalogue/book.php/contents/1-84310-302-8

 

 

 

videos in German Television 
 

WDR 3 (Television) / Reihe Quarks& Co: „Koma – gibt es einen Weg zurück ins Leben?“ (Date 04-09-2007) /

http://www.youtube.com/watch?v=WTYinD4S9uk

 

WDR 3 (Television) / Aktuelle Stunde:"Der lange Weg aus dem Wachkoma zurück ins Leben" (Date 28-11-2009)

http://www.youtube.com/watch?v=mlrFcXlbR_I  

 

ZDF (Television) / Magazin VolleKanne: „Noten statt Worte“ (Date 22-12-2011) 

http://www.youtube.com/watch?v=ypDSuPFZ0bo