1.1

Introduction

Traumatic brain injury is characterised by cognitive and behavioural disorders . Motor after-effects are also common and often have an impact on functional independence . Although neuropsychological and behavioural disorders affect two thirds of patients with traumatic brain injury, our lack of knowledge of these conditions can hamper the rehabilitation and, social and professional reintegration of these individuals for many years after their accident . Post-traumatic behavioural disorders (including hyperactivity, agitation, mood swings, irritability, excitation, lack of inhibition, hostility and distrust) constitute major problems with respect to the management, rehabilitation, and social and family reintegration of these patients . Indeed, it appears that some of these disorders may become chronic or even worsen over time .

A number of recent clinical studies have demonstrated the positive impact of music therapy on the rehabilitation of patients with traumatic brain injury . Developments in functional imaging techniques have made it possible to study the action of music on cerebral functions and verify its impact . Indeed, studies in patients with brain lesions have shown that many different brain areas are involved in processing musical information . Music requires constant collaboration between the two hemispheres and thus encourages more harmonious cerebral activity . Studies have also shown that music therapy stimulates cognitive functions, acts on anxiety, depressive phases and aggressiveness and thus significantly improves mood, communication and independence in brain-injured patients .

A feasibility study (carried out during 2003–2004) on 34 patients with traumatic brain injury allowed us to demonstrate the usefulness of music therapy and to observe the significant results achieved using this technique. Sessions based on playing instruments (active therapy) were able to stimulate both cognitive functions (concentration, memory, etc.) and psychomotor functions (coordination, lateralisation of movements, etc.). Furthermore, receptive therapy (based on listening to music) enabled an improvement in anxiety and/or depression and encouraged the verbal expression of the patients’ suffering. In addition, music therapy could easily be included in a multidisciplinary management programme for patients with traumatic brain injury .

The aim of the present study was to assess the usefulness of music therapy with respect to mood and anxiety–depression in a population of patients with traumatic brain injury institutionalised in a medical rehabilitation centre. The study sought to:

• •
  

  establish whether the method used in the USA by Nayak et al. could be applied in the context of a French rehabilitation center;

  
  
• •
  

  determine any side effects of the method and;

  
  
• •
  

  test the validity of the assessment criteria employed.

1.2

Materials and methods

1.2.4

Methods

Patients meeting all the inclusion criteria and none of the exclusion criteria participated in individual music therapy sessions, which took place once a week for 5 months (i.e., for 20 weeks).

Two music therapy techniques were employed.

1.2.4.1

Receptive music therapy

The new, validated, “U-based” music therapy technique was applied ( Fig. 1 ): it is mainly used in the context of acute and chronic pain and its effects; construction and frequency of application are comparable to a sophrology-type relaxation session. The music (chosen according to the patient’s personal taste) was played into headphones whilst the patient lay supine in an otherwise silent room. These music sequences generally lasted for 20 to 30 minutes and contained several pieces of music; each was a just few minutes long but the pieces were merged and linked, so as to gradually encourage the patient to relax. This effect was achieved firstly by slowing the musical rhythm and reducing the number of instruments in the orchestra, the frequencies and the volume (i.e., the descending phase of the “U”). The patient then moved through the maximum relaxation phase (i.e., the lower bend of the “U”), which was lastly followed by an increasingly dynamic phase (i.e., the ascending phase of the “U”) ( Fig. 2 ).

Receptive music therapy technique: design of “U” sessions.

Mean mood values measured on the face scale before and after music therapy sessions S1, S5, S10, S15 and S20.

1.2.4.2

Active music therapy

This consisted in playing a musical instrument with the patient. Emphasis was placed on interventional techniques such as singing, instrumental or gestural improvisation, song-writing and the execution of rhythmic movements to musical accompaniment. It encouraged stimulation of cognitive functions through memorisation, concentration and attentiveness. Preference was given to the non-verbal register involving movement, thus encouraging both communication and expression in particular .

1.3

Results

1.3.3

Effects of music therapy on anxiety–depression (HAD score)

The patients’ mean level of anxiety at the start of the study was deemed to be moderate (9.8 ± 5 out of 21). For the S1–S5 period, the difference was not significant (−0.8 ± 3.1). However, significant reductions ( p = 0.05) were seen for periods S1–S10 (−3.1 ± 2.5), S1–S15 (−3.3 ± 5.1) and S1–S20 (−3.8 ± 5.4). It is noteworthy that there was a relative improvement of 39% in the level of anxiety between S1 and S20 ( Table 4 and Fig. 1 ).

Table 4

Anxiety and depression (HAD). Values at S1, S5, S10, S15, S20 and differences between measurements.

		n	Mean (S.D.)	Min/max	%	p
Anxiety
Values	S1	13	9.8 (± 5)	1/17	100	N.S.
	S5	13	9.0 (± 3.4)	4/18	92	N.S.
	S10	13	6.7 (± 3.2)	1/13	68	< 0.05 *
	S15	13	6.5 (± 2)	4/10	66	< 0.05 *
	S20	13	6.0 (± 3.4)	2/14	61	< 0.05 *
Differences	S1–S5	13	−0.8 (± 3.1)	−3/7	−8	N.S.
	S1–S10	13	−3.1 (± 2.5)	−5/11	−32	< 0.05 *
	S1–S15	13	−3.3 (± 5.1)	−3/12	−34	< 0.05 *
	S1–S20	13	−3.8 (± 5.4)	−2/14	−39	< 0.05 *

 

Depression
Values	S1	13	6.1 (± 2.9)	0/13	100	N.S.
	S5	13	6.0 (± 3.2)	3/14	98	N.S.
	S10	13	4.7 (± 3.2)	1/10	77	< 0.05 *
	S15	13	4.6 (± 2.9)	0/10	75	< 0.05 *
	S20	13	4.9 (± 3.4)	1/12	80	N.S.
Differences	S1–S5	13	−0.1 (± 3)	−7/3	−2	N.S.
	S1–S10	13	−1.3 (± 1.8)	−2/5	−23	< 0.05 *
	S1–S15	13	−1.4 (± 3.4)	−2/5	−25	< 0.05 *
	S1–S20	13	−1.1 (± 2.1)	−2/5	−20	N.S.

 

* According to Student’s paired t -test; N.S. = not significant; ^* p < 0.05 = significant.

The baseline depression score was low (6.1 ± 2.9 out of 21). For this parameter, the difference (−1.3 ± 1.8) between S1 and S10 was significant ( p < 0.05), with a relative improvement of 23%. The differences remained significant for S1 versus S15 (−1.4 ± 3.4), with a relative improvement of 25%. However, the results were no longer significant for S10 versus S20 ( Table 4 and Fig. 3 ).

Change over time in anxiety and depression for S1, S5, S10, S15 and S20.

1.4

Discussion

Significant before-versus-after improvements in the primary endpoint (mood) were observed for each of the five assessed music therapy sessions. Enhancement of the effect was also observed with the increase in the number of sessions, which could suggest a dose-dependent effect ( Table 3 ). This improvement was around 43% following the first weekly session and rose to 61% by the 20th session. Our results confirmed those observed by Nayak et al. in the context of a controlled, randomised study performed in 2000 in an American functional rehabilitation center. The authors demonstrated the value of music therapy for improving mood and behaviour in patients with traumatic brain injury. During Nayak et al.’s study, the mean ( n = 10) primary endpoint score (a patient-scored face scale) fell from 4.6 (± 1.8) to 2.8 (± 1.3), with a relative improvement of 39%. During our study, we achieved an improvement of 2 (± 2) points, with scores falling from 4.6 (± 3.2) after the first session to 2.6 (± 2), i.e., a 43% improvement. Our results were thus comparable with those reported by Nayak et al. and thus confirm the short-term efficacy of a music therapy session with respect to mood. Further studies are necessary to determine how long this effect is sustained after sessions are discontinued – an assessment 1 hour after the end of the session would have been interesting. Nevertheless; we obtained significant differences between the initial assessment (i.e., just before the first session) and the start of the fifth, 10th, 15th and 20th sessions ( p < 0.05).

The results concerning anxiety–depression (HAD) at S10 demonstrated a significant difference for both components ( p < 0.05). The significant effect of music therapy on anxiety was seen to persist until S20. The results concerning the affective component of symptom changes showed that the effect of music therapy was sustained. One week after the discontinuation of sessions, the anxiolytic effect was still present.

In terms of the various mechanisms involved in music–subject interaction, it seems very likely that music can modify the course of disorders through its sensory, cognitive, affective and behavioural effects. Hence, music therapy is mainly active on memory disorders, anxiety–depression and agitation.

The effects of receptive music therapy are usually related to the fact that individualised musical listening markedly relieves painful experiences. The impact of this type of therapy may be due to music-specific neuropsychological effects that act on sensory components (causing contra-stimulation of afferent fibres), cognitive components (often deflecting attention by creating images and banishing memories of pain), affective components (modifying moods associated with states such as depression or anxiety and thus relieving tension and feelings of anguish) and behavioural components (acting on muscle hypotonia and psychomotility) . The effects of music therapy are based on the impact of music on different components in the overall, painful experience and changes in the perception of pathological disorders .

Psychological factors may also contribute to reducing affective symptoms: the music is chosen as a function of the patient’s personal taste and thus in response to individual listening needs. Talking to patients following a session may thus provide an opportunity for some of them to free themselves of their problems and encourage a supportive, listening relationship .

Music therapy has a considerable effect on mood. In the context of our study, the anxiolytic effect of music therapy was probably strong because of its combination with all the other rehabilitation activities. However, our work also clearly demonstrated a clinically relevant short-term effect of music therapy, with the patients acting as their own controls (i.e., pre- and post-session assessments).

This type of technique may require a large number of sessions. Emphasis should also be placed on adapting the style of music (classical, modern, jazz, easy listening, rock, electronic, world music, etc.) to the patient’s receptiveness .

Our aim was to demonstrate the feasibility and short-term efficacy of music therapy in patients with traumatic brain injury acting as their own controls. These initial findings provide a good working basis for a controlled, randomised study for assessing the value of music therapy; the goal would be to add a new therapeutic weapon (devoid of side effects) to the already wide-ranging arsenal available for the rehabilitation of patients with traumatic brain injury. Ultimately, this will enable a comparison with other similar therapeutic interventions, such as speaking or singing.

1.5

Conclusion

The present preliminary study suggests the value of music therapy in patients with traumatic brain injury as part of a multidisciplinary management programme. Music therapy contributes to functional and cognitive rehabilitation by improving mood and the anxiety–depression components in severe patients with traumatic brain injury. The intentional use of the potential and properties of music acts through many interacting mechanisms (be they sensorial, cognitive, affective or behavioural) and thus enables a direct impact over time on all these components in the patient.

2.1

Introduction

Le traumatisme crânien se caractérise par des troubles cognitifs et du comportement . Les séquelles motrices sont aussi fréquentes et ont souvent des conséquences sur l’indépendance fonctionnelle . Ces troubles neuropsychologiques et comportementaux touchent les deux tiers des patients et leur méconnaissance entrave la rééducation et la réinsertion socioprofessionnelle de ces personnes des années après l’accident . Ces nombreux troubles du comportement post-traumatiques incluent l’hyperactivité, l’agitation, la labilité, l’irritabilité, l’excitation, la désinhibition, l’hostilité et la méfiance, et sont source de difficultés majeures dans la prise en charge, la réadaptation et la réinsertion sociale et familiale de ces blessés . Il semble que certains de ces troubles se pérennisent, voire parfois s’amplifient avec le temps .

Quelques études cliniques récentes ont permis de mettre en évidence le rôle favorable de la musicothérapie dans la réadaptation des traumatisés crâniens . L’évolution des techniques d’imagerie fonctionnelle a permis de vérifier et d’étudier l’action de la musique sur les fonctions cérébrales . Les études auprès de personnes atteintes de lésions cérébrales ont permis de montrer la diversité des zones du cerveau impliquées dans le traitement de l’information musicale . La musique demande une collaboration constante entre les deux hémisphères qui favorise une activité cérébrale plus harmonieuse . Les études montrent ainsi que la musicothérapie stimule les fonctions cognitives, agit sur l’anxiété, les phases dépressives, l’agressivité et améliore ainsi de façon significative l’humeur, la communication et l’autonomie des patients cérébrolésés .

Une étude de faisabilité réalisée durant l’année 2003–2004 sur 34 patients cérébrolésés nous avait permis de démontrer la faisabilité et d’observer des résultats significatifs de la musicothérapie chez les traumatisés crâniens. Les séances basées sur la pratique instrumentale, dite active, ont permis de stimuler les fonctions cognitives (concentration, mémoire…) et psychomotrices (coordination, latéralisation des mouvements). La technique réceptive, basé sur l’écoute musicale, a permis une amélioration des troubles de l’anxiété–dépression et a favorisé la verbalisation de la souffrance des patients. De plus, la musicothérapie s’est intégrée facilement dans un programme pluridisciplinaire de prise en charge des traumatisés crâniens .

L’objectif de cette étude est d’évaluer l’intérêt de la musicothérapie sur l’humeur et sur l’anxiété–dépression dans une population de patients cérébrolésés institutionnalisés en foyer d’accueil médicalisé. Elle a cherché à vérifier l’applicabilité de la méthode utilisée aux États-Unis par Nayak et al. , dans le contexte d’un établissement médicosocial français, à rechercher les effets secondaires éventuels et à tester la validité des critères de jugement utilisés.

2.2

Matériels et méthodes

2.2.4

Méthodes

Les patients répondant aux critères d’inclusion ont participé à des séances individuelles de musicothérapie. Les séances ont eu lieu une fois par semaine pendant cinq mois (20 semaines).

Deux techniques de musicothérapie ont été utilisées :

2.2.4.1

Musicothérapie réceptive

Nous avons utilisé la nouvelle technique de musicothérapie validée du montage en U ( Fig. 1 ) : essentiellement utilisée dans le cadre de douleurs aiguës et chroniques, son effet, sa construction et sa fréquence d’application sont comparables à une séance de relaxation de type sophrologie. La musique, choisie en fonction des goûts personnels du patient , a été diffusée au casque en position allongée, dans une salle silencieuse. La séquence musicale dure généralement de 20 à 30 minutes. Elle assemble plusieurs morceaux de quelques minutes chacun, fondus et enchaînés dans le but d’induire progressivement le patient à la détente. L’effet agit tout d’abord par une diminution du rythme musical, de la formation orchestrale, des fréquences et du volume (phase descendante du « U »). Ensuite, le patient traverse la phase de détente maximum (partie basse du « U »), qui est enfin suivie par une phase redynamisante (branche ascendante du « U ») ( Fig. 2 ).

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