DocumentIntroductionA delay of rehabilitation after brain injury could havea negative influence on the final outcome of the patients.Active, improvised music therapy based on the approachof Nordoff and Robbins [1] appears to offer a valuableform of adjuvant therapy in the early rehabilitation. Thesame approach was also utilized by Gustorff [2] withcomatose patients. Active, improvised music therapy ismusical improvisation between patient and therapist bysinging or by means of different instruments (keyboard,percussion, wind), according to the vital functions (pulserate, breath), the neurological conditions (degree of con-sciousness, behavioral disorders) and the motor abili-ties of the patient.The Italian rehabilitation hospital Fondazione SantaLucia, IRCCS, Rome, Italy, in cooperation with the Ger-man University of Witten-Herdecke started a prelimi-nary study to verify the specific effect of active, impro-vised music therapy on the communicative abilities andinteraction with the environment of patients during re-covery from prolonged coma. The study concerned pa-tients who suffered from prolonged coma and who havenot yet recovered their verbal communication.In particular in the last years we investigated the effi-cacy of improvised music therapy on psychomotor agi-tation after severe brain injury, associated or not withinertia.Psychomotor agitation has been described as a fa-vorable sign of recovery in the brain-injured patients [3],but may also compromise the collaboration during therehabilitation program.In the first phases of coma recovery the improvisedmusic therapy is based primarily on the musical rela-tionship, where the patient is encouraged to play, whileaccompanied by a therapist, a variety of instruments (per-cussion, keyboards and wind instruments), and also tosing and vocalize. Playing together, the music therapistimprovises music with the patient and encouraged himor her to create a musical dialogue, stimulating the ini-tiative and the active participation of the patient andsometimes interrupting undesired behaviors.Active music therapy in the rehabilitationof severe brain injured patients during coma recoveryRita FORMISANO, VincenzoVINICOLA, FrancescaPENTA, Mariella MATTEIS,Stefano BRUNELLI and Jurgen W. WECKELFondazione Santa Lucia, Ospedale di Riabilitazione, IRCCS, Rome, ItalySummary. - Active improvised music therapy may offer an adjuvant form of treatment in the early rehabili-tation of severe brain-injured patients. Active music therapy consists of musical improvisation between patientand therapist by singing or by playing different musical instruments, according to the vital functions, the neuro-logical conditions and the motor abilities of the patients. We studied 34 severe brain-injured patients with a meancoma duration of 52 days37.21 and a mean interval from coma onset to the beginning of rehabilitation of 154days on average. Our preliminary results show a significant improvement of the collaboration of the severebrain-injured patients and a reduction of undesired behaviours such as inertia (reduced psychomotor initiative)or psychomotor agitation.Key words: severe brain injury, coma, rehabilitation, active music therapy, complementary alternative medi-cine.Riassunto (La musicoterapia attiva nella riabilitazione dei gravi cerebrolesi). - La musicoterapia attivaimprovvisata pu offrire una forma aggiuntiva di trattamento nella riabilitazione dei pazienti con gravicerebrolesioni. La musicoterapia attiva consiste in improvvisazione musicale tra paziente e terapista attraverso ilcanto o luso di diversi strumenti musicali, compatibilmente con le funzioni vitali, con le condizioni neurologi-che e con le abilit motorie dei pazienti. Abbiamo studiato 34 cerebrolesi gravi con una durata media del comadi 52 giorni37,21 e un intervallo medio dal coma allinizio della riabilitazione di 154 giorni. I nostri risultatipreliminari mostrano un miglioramento significativo della collaborazione dei pazienti con gravi cerebrolesioni euna riduzione di comportamenti indesiderati come linerzia (ridotta iniziativa psicomotoria) o lagitazionepsicomotoria.Parole chiave: grave danno cerebrale, coma, riabilitazione, musicoterapia attiva, medicina complementarealternativa.Ann. Ist. Super. Sanit, vol. 37, n. 4 (2001), pp. 627-630The aim of the study was to evaluate the effect ofactive, improvised music therapy on the communicativeand interaction abilities of the patients and on thebehavioral disorders of the patients during comarecovery.MethodSingle-case-design. We examined 34 patients withprolonged coma (more than 15 days), with GlasgowComa Scale [4] 8 in the acute stage and Glasgow Out-come Scale [5] (GOS) 3 (severe disability at the ad-mission time in the study). Lack of verbal initiative wasthe only criterion for the inclusion. Patients were exam-ined by means of GOS, DisabilityRatingScale - DRS[6], Coma Recovery Scale (CRS) [7] and Post-Coma-Scale (PCS) [8]; CRS and PCS both examine the inter-active abilities of the patients with the environment, in-cluding the presence of undesired behaviors such as in-ertia and/or psychomotor agitation. The treatment pro-tocol consists of six different evaluation times: on T0 atadmission time; on T1 before starting music therapy(baseline) at 15 days after the starting of the routine re-habilitation program (physical therapy, cognitive therapyfor all patients; respiratory and orthoptic therapy whenneeded); on T2 after 15 days from the starting of musictherapy (as additional treatment to the routine rehabili-tation program); on T3 at one month from the starting ofmusic therapy; on T4 after two months, only if the mu-sic therapist and the examiner record improvements inthe patients neurological situation and on T5 one monthafter the suspension of the music therapy (follow up).The treatment of music therapy was based on the ap-proach of NordoffandRobbins [1] and was performedon 3 times a week for 20-40 minutes (depending on thelevel of attention of the patient) and without changingany pharmacologic therapy during the period of musictherapeutic treatment.The evaluation was also performed by the music thera-pist, who examined the different video recordings of themusic therapeutic sessions and by a blind examiner whojudged randomised examples of video recordings foreach patient by means of a semi-quantitative scale ofthe clinical modifications (+: improved; =: unchanged;0: worsened). The clinical modifications examined werethe followings: psychomotor initiative, psychomotoragitation, interaction with the environment.The 34 patients included 17 males and 17 females,aged between 13 and 70 years, with a mean age of 35.94years (range: 13-70). Eighteen of them suffered fromtraumatic brain injury, the others hypoxic, ischemic orhemorrhagic coma. The heterogeneity of etiology wasnot an exclusion criterion, because the patients sharedthe diagnosis of severe brain injury (GCS