Correction: The effect of musical sensory orientation training in improving consciousness level in patients with disorders of consciousness: a pilot study
Year: 2026
Type: erratum
Abstract: Disorders of consciousness (DoC) are states of impaired consciousness resulting from serious brain injuries, and includes coma, vegetative state, and minimally conscious state, characterized by reduced levels of arousal and alterations in the content of consciousness (Bender et al., 2023). Patients with DoC face longterm, complex medical and caregiving challenges, presenting one of the most pressing issues in the field of neurorehabilitation. In recent years, several arousal techniques have been developed in the field of DoC rehabilitation, such as pharmacotherapy, hyperbaric oxygen therapy, and brain neuromodulation techniques, which have achieved some success in the treatment of coma (Edlow et al., 2021;Yang et al., 2020). While pharmacologic interventions (e.g., amantadine, zolpidem) have shown promise in enhancing arousal in chronic DoC, their utility is limited by tachyphylaxis, adverse effects (e.g., agitation, insomnia), and variable efficacy across injury endotypes (Giacino et al., 2018;Edlow et al., 2021). Placebo-controlled trials in this vulnerable population also raise ethical concerns, as withholding potential therapies may delay recovery (Fins, 2015). Furthermore, heterogeneity in structural and functional connectivity among DoC patients leads to inconsistent treatment responses, underscoring the need for personalized, noninvasive approaches (Edlow et al., 2021;Thibaut et al., 2019). Moreover, there is insufficient evidence-based support for their use in the arousal treatment of some patients with chronic DoC, and most of the treatments have certain risks (Yao et al., 2023).With the advancement of neuroscience, neurologic music therapy has been established as a distinctive treatment for DoC. Music, as a sensory stimulus transmitted through auditory receptors, exerts varying effects on patients' attention and auditory perception depending on its style, tonality, and tempo (Zhang et al., 2021;Liu et al., 2022;O'Kelly et al., 2013). Musical sensory orientation training (MSOT) is an emerging technique of neurologic music therapy that aims to improve the state of consciousness and cognitive function. In recent years, MSOT has gradually been implemented in clinical practice, and research into its mechanisms of action has commenced (Xiao et al., 2023). MSOT utilizes music as a medium to stimulate the sensory systems, thereby facilitating the rehabilitation of patients with DoC. Its fundamental principle is to stimulate the auditory, visual, tactile and motor sensory systems of patients through the rhythm, melody, pitch, and timbre of music, stimulating their sensory perception and motor function (Thaut and Hoemberg, 2014). Compared with traditional arousal therapies, MSOT is non-invasive, safe, and easy to operate, with no side effects. The technique leverages recorded music or live music performances to improve attention retention, enhance the execution of simple commands, and improve cognitive function by engaging patients in simple musical activities, either passively or actively. Various elements of music activate cognitive functions such as working memory, episodic memory, language processing, mental imagery, and attention (Boltzmann et al., 2021). Music therapy interventions employ live music, where therapists improvise on the keyboard with varying rhythms, melodies, and sound effects, eliciting emotional fluctuations of tension, anticipation, and humor (Lichtensztejn et al., 2014). Therapists incorporate various musical elements into patients' responses, creating opportunities for meaningful interactions.The study is significant in several areas. Firstly, in the fields of neurology and rehabilitation medicine, DoC is a major challenge and quite difficult to manage. Patients with DoC typically exhibit a range of cognitive, sensory, and motor impairments that severely affect their physical functioning and quality of life (Bender et al., 2023). Effective interventions are crucial to improving the level of consciousness of the patients. Secondly, MSOT is a promising approach that shows potential in improving the prognosis of patients with DoC (Thaut and Hoemberg, 2014;Boltzmann et al., 2021;Lichtensztejn et al., 2014). Further exploration of the efficacy of MSOT could contribute to the development of evidence-based medical interventions. Thirdly, the implementation of MSOT currently lacks standardized guidelines and protocols. Our study integrated auditory, visual, and sensory stimuli through the use of musical elements. During the treatment, the assessment method of the music therapy for DoC was adopted, allowing for concurrent treatment and evaluation. By combining the listening of preferred music with live improvised music interventions, the specific steps of the MSOT were formulated, thereby concretizing the MSOT approach. Therefore, this pilot study prospectively evaluated the therapeutic efficacy of MSOT for consciousness enhancement in DoC, while systematically assessing its clinical implementation feasibility, thereby establishing an empirical foundation for subsequent phase III randomized controlled trials.Given the absence of prior research implementing MSOT in patients with DoC, the expected effect size remains uncertain. We conservatively assume a medium-to-large effect size range (Cohen's * d * = 0.5-0.8). For the generalized estimating equation (GEE) analysis [α = 0.05; power (1-β) = 0.80], with intervention condition (MSOT vs. video-based multisensory stimulation) as the between-subject factor and time [week 1 (t0), week 5 (t1), week 8 (t2)] as the within-subject factor, we targeted 80% statistical power (corresponding to effect size * f * = 0.30). Power calculations using G * Power 3 indicated that an effective sample size of * n * = 17 per group would achieve 80% power for an effect size of * d * = 0.65 (within the projected medium-to-large range), yielding a total sample size of n = 34. To account for an anticipated 10% attrition rate due to data missingness (e.g., invalid questionnaires or participant dropout), we inflated the per-group sample size to 22, resulting in a final total of n = 44. This sample size aligns with comparable randomized controlled trials (e.g., Zhang et al., 2021;n = 40) and ensures sufficient power to detect effects on primary outcome measures.The study enrolled patients diagnosed with DoC admitted to Hunan Provincial People's Hospital between March 2024 and March 2025. Convenience sampling initially identified 44 candidates, of whom 42 met the eligibility criteria following the exclusion of two ineligible patients (Figure 1). Inclusion criteria required: (1) met the diagnostic criteria for DoC according to international consensus guidelines; (2) age ≥ 18 years. Exclusion criteria comprised: (1) acute critical illnesses with imminent risk of clinical deterioration; (2) neuroimaging-confirmed structural auditory pathway lesions (congenital malformations, traumatic injuries, or acquired pathologies).A crucial team member, a doctor of the Department of Rehabilitation Medicine, assisted in presenting the study to potential participants. Posters were displayed in the wards and clinics, detailing the study's purpose, content, risks and benefits. Written informed consent was obtained from all patients' legally authorized representatives prior to participation. Participants were allocated to either the intervention (n = 21) or control group (n = 21).Patients in the intervention group underwent structured MSOT sessions five times weekly, each comprising 30 min of music-mediated multisensory training, over an 8-week period (Figure 2). Specific implementation steps for MSOT showed in Table 1. The MSOT was developed through a systematic synthesis of evidence from prior neurorehabilitation studies (Raglio et al., 2014;Binzer et al., 2016;Magee, 2018). The core component of MSOT is the development of an individualized treatment Prepared stage 1: Preparedness The goals and intervention plans for MSOT were determined based on the patient assessment results.According to the patient's preference, 1-2 pieces of classical music, 2-3 preferred songs, and 1-2 rhythmic music tracks were selected.Greeting and farewell songs-titled "Hello Song" and "Goodbye Song" respectively-that incorporate personalized patient information, such as their names and ages. Four phrases with repetitive musical and linguistic structures were used to maintain the simplicity of the musical composition, including simple rhythms and recurring melodies. The maximum range of the melody were kept within a single octave. Western tonalities of the same length, such as minor or major keys, were used. The lyrics included "hello"/"goodbye" and the patient's name.Prepared stage 2: Establish a breath-synchronized musical rhythm At the onset of treatment, the patient's respiratory rate was monitored. A note was played each time the patient exhaled: a single low note represented a harmonic progression, such as I-IV-V-I.The foundational rhythm and tempo were provided for the opening music, gradually building up to a rhythm based on the patient's respiratory rate.The Hello Song was played and sung. One verse was sung at a lower volume, while another verse was sung at a higher volume.The responses to changes in force and intensity were evaluated.The entire verse with the patient's name was sung at least twice. This step was extended if the patient exhibited eye contact, motor responses, or attempts to vocalize.Brightly colored small percussion instruments were positioned in the midline of the patient's visual field. If the patient turned to one side, the stimulus was positioned in the midline of his/her visual field.When the object was fixed, the therapist waited for the patient to "lock" his/her eyes on the target object. Only when the patient's gaze was fixed on the target, the target was slowly moved from the center of the visual field to the four quadrants around the visual midline: to the left (returning to the center), right (returning to the center), upward (returning to the center), and downward (returning to the center).The target object was moved at a speed that the patient could comfortably track. The target object was moved as far as possible within the range of each quadrant that the patient could possibly track.In some cases, it was helpful to tell the patient what he or she needed to do: "Look toward the [target object's name], [patient's name]."Using a melodic instrument, three to four notes with significant contrast in pitch were played. Pitches used in different registers (for example, C in the three-line octave and F# in the six-line octave) formed dissonant intervals, such as C and F#).If the patient's preference for musical instruments was unknown, a high-pitched handbell was used.Auditory stimuli were presented where the patient could not see the stimuli. The musical sound was presented to the patient alone for up to 10 s in the auditory mode.In some cases, it was helpful to tell the patient what he or she needed to do, for example, "[patient's name], turn toward the direction of the sound." The stimuli were presented outside the patient's field of vision, but within the range where the patient could demonstrate physical intent, for example, to turn toward the direction of the sound.Two musical instruments with very different sounds, such as one with and one without high pitches were played, while giving verbal instructions to turn toward the direction of a specific sound, for instance, "I am going to play two sounds for you. Please turn toward the direction of the guitar sound."Classical music was played, while the patient's tracking of the directions of visual and auditory stimuli was observed and recorded.A simple percussion instrument was placed in the patient's hand, and the patient was given performance instructions while listening to his/her preferred music.The assistant provided support as needed to help patients play the percussion instrument in time with the music. The patient's responses to performance instructions, as well as to changes in the melody, rhythm, and pitch of the music were observed and recorded.Rhythmic songs were played or sung with performance instructions being continuously given to the patient.If needed, the assistant might help the patient touch the instruments.The patient's responses to performance instructions, as well as to changes in the melody, rhythm, and pitch of the music were observed and recorded.The Goodbye Song was played and sung, and the patient's responses were observed. Gu et al. 10.3389/fnins.2025.1610811 plan based on patient assessment, a dynamic adjustment process through breath synchronization, multi-sensory stimulation (visual tracking/auditory localization), structured musical interactions (customized greetings/farewells tracks), and rhythmic synchronized performance combined with real-time observational feedback. General treatment principles of MSOT showed in Supplemental material 1. All sessions were jointly administered by a certified neurologic music therapist (NMT) and a trained research assistant, with both personnel completing a 20-h competencybased training program in DoC-specific music intervention protocols prior to study initiation.In addition to conventional treatment, patients in the control group were exposed to video-based multisensory stimulation consisting of two components: (i) customized audiovisual recordings of family/friends' daily activities; (ii) passive viewing of neutral short videos via a tablet device (e.g., nature scenes, abstract animations). To standardize tactile input, neutral objects including a plastic comb, textured rubber ball, and silicone massage stick were passively placed in patients' palms for non-directed tactile exploration during sessions. Interventions were administered in 30-min sessions five times weekly over 8 weeks, with each session jointly supervised by a certified rehabilitation therapist from the research team and the patient's primary caregiver to ensure protocol adherence (Figure 3).Coma Recovery Scale-Revised (CRS-R) (Giacino et al., 2004):The of assessing the auditory visual motor and arousal of the on patients were diagnosed with minimally conscious state which includes two as and or from To the risk of two the daily for five The from was used for the et al., of the et al., we identified several for systematic during therapeutic interventions, of eye gaze orientation toward auditory and name of through gaze of and of in motor To ensure of responses, all sessions were following of informed with trained through to the the for the was were a for five in week 1 week 5 and week 8 of the The from each assessment period was used. were by the at and process for the control were using for The was used to the of the data were as and data were as The and were used to the of the of the patients between the two A generalized estimating equation was developed to the changes in outcome with outcome at each time as the and and the between treatment and time as the were using the with statistical as analysis was between the two as from onset to the of arousal used and interventions of such significant were observed between the 0.05; see Table the of the intervention (MSOT) and control their at the study and clinical with no significant in age vs. years, = vs. = or total hyperbaric oxygen therapy vs. = of therapies (e.g., were also arousal therapies and (e.g., brain were vs. and levels (e.g., and 5 vs. showed no This the of subsequent outcome as were 3 the of the generalized estimating equation (GEE) which the effects of the intervention across The analysis significant interactions for all Recovery Scale-Revised (CRS-R) visual, and total as well as all to name sound of instruments or following at both and The significant interactions that the of over time between the intervention group and the control with the intervention group instance, the significant for auditory function at = = that the intervention group achieved a from the control with an of at the effect for at was = = that the intervention group achieved a the control group at to significant effects were also for visual function = = = motor function = = = = function = = = = function = = = arousal = = and total = = as well as of including responses to name = = sound tracking = = of instruments or objects = = = following instructions = = that the intervention not functional recovery across sensory, and but also leads to in complex to the control which are critical for patients with of the significant simple effects. a of and changes across the three Table the of a simple effects analysis changes over time using The intervention group across all to the control For example, in auditory the intervention group showed a significant of from to the control group a but also significant of for visual responses to name of and motor function were significant in the intervention group but in the control group = The same of significant was observed for and sound This the of the the intervention group from to as by total of which far the concurrent in the control group = the of the intervention in both functional and with significant for clinical no significant in visual, total or at and week 5 By week 8 the MSOT group exhibited function = = arousal = responses to = sound tracking = and following instructions = no significant intervention effects were for auditory visual motor of instruments or objects or at assessment including in Table as an treatment, is of for the rehabilitation of patients with DoC. The of this study showed that with the of MSOT patients with DoC showed significant in all of the and the total as well as in the of that MSOT is effective in improving the consciousness levels of patients with DoC, which is with the of studies on the effect of live music on improving consciousness in patients with DoC et al., 2022;O'Kelly et al., et al., et al., et al., that musical stimuli may responses verbal stimuli in patients with DoC et al., 2023). In live the adjustment of musical elements such as rhythm, pitch, and to support and some of the exhibited by patients such as of small and patient in musical and In the use of the patient's preferred music also enhance the of functions in patients with DoC et al., Therefore, in this the intervention protocol of MSOT the Gu et al. 10.3389/fnins.2025.1610811 between both at and according to of musical pieces and the patients' musical The patients with DoC were or passively through the use of arousal music, live performances of their preferred music, and improvised songs, which their of this study also no significant in all outcome between the MSOT and control at week 5 of the at week 8 of the the MSOT group showed significant in and arousal of the as well as in the of responses to sound and with the control that the of MSOT intervention its with over Furthermore, the MSOT intervention was effective the control in improving arousal and responses in patients. The of music therapy in improving the level of consciousness in patients with DoC in its to enhance arousal levels and as well as opportunities for et al., in name tracking arousal and which may recovery of functions (e.g., motor from across if (e.g., The of this study this In the MSOT improvised music is which the name of the patient and has a rhythm based on the patient's respiratory rate 2018). The of preferred music a patient that during live performance to This approach while opportunities for musical thereby the of the 8-week MSOT intervention not a significant in improving auditory, visual, and functions in patients with DoC with the control This of significant in specific is to the insufficient of the which may not have been to in arousal and attention into functional recovery in motor and that for patients with motor following or traumatic brain an intervention three is et al., et al., et al., 2023). most studies that the training period for the rehabilitation of cognitive and functions might et al., Therefore, based on evidence from comparable rehabilitation motor and cognitive MSOT trials to effects on and cognitive functions a intervention of 3 with (e.g., ≥ to and complex cognitive observed of treatment significant emerging at week 8 week 5 two potential multisensory may to structural in demonstrate that combined stimulation over ≥ in the and primary sensory traumatic injury et al., et al., 2021). This aligns with studies functional connectivity between auditory and of intervention in DoC patients (Boltzmann et al., 2021). through repetitive musical (e.g., patient's name with specific melodic may in in patients trials over to et al., mechanisms MSOT through both sensory pathway and cognitive by recent brain stimulation studies et al., 2018). The analysis significant in following with patients from and from was through protocol adherence across all intervention of this study demonstrate that effective in improving consciousness levels in patients with DoC and in clinical the intervention in studies may its therapeutic study has several Firstly, the study was limited by such as and treatment resulting in that is to that of a randomized controlled Secondly, the of the intervention was exploration of the effects of a intervention Thirdly, all outcome used were assessment and the to some by and in of the control the use of video-based multisensory stimulation as the control while a ethical for this is not a or of the This it may not control for therapeutic effects, such as the attention from the of the or the sensory provided by the the observed between might the specific therapeutic elements of the MSOT the of the the specific efficacy of MSOT research incorporate outcome (e.g., and employ control such as interventions or control for to the specific effects and mechanisms of MSOT intervention in
Source: Frontiers in Neuroscience
Authors: Jiayi Gu, Wei Long, Siqin Zeng, Liang Qin, Yi Dong, Cuini Fang, Xiaoying Zhang
Language: English
Subfield: Epidemiology
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $3,801
OpenAlex ID: W7154173990
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