By Jennifer A. Rathbun, MM, MT-BC
Not the Same Old Song Using music therapeutically in the rehabilitation hospital setting. Music affects many of us on a daily basis. We may use soft music as a means for relaxation after a hard day's work or strong rhythmic beats to motivate us during hard workouts. Without realizing it, we are using music to achieve our own goals. Since we naturally use music to attain our own goals, it seems logical to extend this concept to rehabilitation goals. Through the years, the use of music in therapy has emerged as a new treatment modality. Music therapy, as defined by the American Music Therapy Association (AMTA), is "an established health service, similar to occupational therapy and physical therapy. Music therapists assess emotional well being, physical health, social functioning, communication abilities, and cognitive skills through musical responses."1 Treatment plans are designed for individuals and groups based on patient needs. Music is then used to facilitate the achievement of goals. A common misconception is that patients must be musically inclined or have experience in music to be eligible for music therapy services. This is not the case. Music therapists can modify musical instruments so patients with no musical skill or background can still make music. Another misconception is that music therapy is therapy for musicians with injuries. Unfortunately, music therapy is a misnomer. While patients with physical injuries go to physical therapists, patients with injuries resulting from overuse while playing an instrument do not go to music therapists. These musicians would go to physical therapists as well. In a rehabilitation setting, music is used as a tool for motivating and cuing movement, engaging and sustaining attention, stimulating verbal expression, and mediating emotional responses. A specialized certification of music therapy is neurologic music therapy (NMT), the therapeutic application of music to cognitive, sensory, and motor dysfunction due to neurologic problems of the human nervous system. NMT requires additional training in neuroanatomy/physiology, brain malfunctions, and cognitive and motor functions. NMT is evidence-based, and treatment modalities are standardized, based on scien- tific knowledge of music perception.2 Rhythm In Music With Gait Training Walking is an intrinsically rhythmic action. Recently, studies exploring the sensorimotor connection between rhythm in music and rhythm in movement have been published with positive results.3,4 McIntosh et al3 studied the effect of rhythm on gait parameters in stroke and Parkinson's patients. After a walking cadence was calculated, patients were asked to walk to a musical beat, placing heel strikes on the strong rhythmic pulses. The study found that the rhythm in the music operates as a tool for entrainment because strong rhythmic patterns attract the timing of motor responses. In addition, the rhythm in music is a pattern that is easily predictable. Thus, patients are able to predict when to step because they can anticipate when the next beat will occur. Research has shown that gait parameters, such as velocity, stride symmetry, and variability of muscle activation, improve with the presence of a rhythmic timekeeper.4 Clinically, this idea of rhythmic auditory stimulation (RAS) is carried over into exercises involving balance, strength, and endurance to improve functional performance during walking. In the brain injury program at The Institute for Rehabilitation and Research (TIRR) in Houston, music therapists team with physical therapists during gait and balance exercises. Using music chosen by the patients, music therapists supply the rhythmic stimulus to cue patients when to step-whether forwards, backwards, or sideways. Patients step with the beat and time movements within the rhythm. The music therapists' expertise is called on to provide patients with preferred music containing the most appropriate musical elements for clear cuing in order to enhance the chances for success. Music therapists often use live music to manipulate the rhythm to match the patients' needs. This type of manipulation cannot be done with recorded music. Music As A Diversion At TIRR, music therapists are also involved in cotreatments with physical therapists and occupational therapists in order to provide a stimulus to engage attention during functional activities. For example, patients are often involved in weight bearing on affected limbs in order to stimulate muscle activation. This activity can be tiring and often painful. Music therapists provide interventions that not only engage the attention away from the pain, but also facilitate the physical or occupational therapist's goals of weight bearing. Cognitive Rehabilitation The brain likes patterns. Music is an exquisite example of combinations of patterns, whether it is a repetitive rhythm or the tension and release of chord resolution. Patients are easily engaged in music and are better able to sustain attention during physical or cognitive tasks with the presence of music. Music's familiarity comforts patients, while its novelty sustains attention. Another example of the use of music in cognitive tasks as a mnemonic device. Before elementary school, we learned the alphabet by singing the letters to a tune. As adults, we find ourselves humming the tune in order to figure out where to file a patient's chart alphabetically. In rehabilitation, music therapists write short songs for sequencing tasks, remembering schedules, and recalling orientation information. Patients learn these songs from the music therapists and, therefore, are better able to recall the information placed within the songs. Music, Speech, and Language Melodic intonation therapy (MIT) has been widely used by speech-language pathologists with aphasic patients. According to Sparks and Holland,5 MIT is a step-by-step procedure that uses melody based on the natural prosody of functional phrases to stimulate verbal expression. Later, the melody is faded into chant and finally, the chant is faded into normal speech. At TIRR, both musical speech stimulation (MSS) and a modified form of MIT are used during sessions with a music therapist and speech-language pathologist. MSS is the musical form of phrase completion. It uses the unimpaired ability to sing in order to facilitate spontaneous verbalizations. Patients are asked to complete phrases within familiar songs, such as "You Are My Sunshine." This automatic singing is practiced and then transferred into functional expression as automatic speech emerges. Apraxic patients benefit from MSS because familiar songs have a predictable rhythm, which facilitates oral-motor timing. In addition, songs are directional-the chord progressions, or musical building blocks, lead the song to resolution. Music therapists also provide simple instruments to facilitate the coordination of the breathing mechanism. The music made by these instruments, such as harmonicas, recorders, and melody horns (instruments with a small keyboard connected to a mouthpiece), motivates the patients to exercise breath control. A Mediating Response Music's aesthetic qualities provide an excellent medium for self-expression. Music therapists explore thoughts and feelings regarding coping and adjustment through a variety of interventions, such as song writing, lyric analysis, music and imagery, and music improvisation. Berlyne6 postulated that aesthetic stimuli act as a "mediating response" between emotional reactions to the music and present emotional states. A music therapist can provide a musical piece in order to elicit predicted emotional reactions. This process brings forth emotions that may affect progress in therapy. At TIRR, patients attend a psychosocial group where a music therapist and a social worker cotreat to explore emotions such as love, anger, and frustration. The music brings forth the experience of emotions and mood states, and thus discussion ensues regarding exploration of these feelings. Music therapists must complete coursework from an approved college, fulfill an internship, and sit for the national board certification examination. Undergraduate coursework includes studies in music as therapy, psychology, music theory and history, biology, social and behavioral sciences, disabilities, and anatomy and physiology. How is it funded? Insurance companies are recognizing the advantages of covering music therapy as they respond to increasing market demand for greater patient choice of health care services. Music therapists are using current procedural technology (CPT) codes to identify services to case managers, review directors, or insurance adjusters. Many hospitals view music therapy as part of the total rehabilitation program, which is reimbursed through per diem billing. Health care plans are also reimbursing music therapy services based on medical necessity. The therapeutic use of music in therapy is both time- and cost-effective. When paired with other therapies, music therapy increases the patient's ability to participate in treatment, thus accomplishing goals faster and more resourcefully. With the advancing changes in health care, patients deserve a better chance to achieve goals in a short but intensive time period. Music therapy contributes to the rehabilitation process by facilitating quick and intensive goal achievement through creative and scientifically proven treatment. For more information and to find a music therapist in your area, please contact the AMTA at (310) 589-3300 or via the Web: www.musictherapy.com Jennifer A. Rathbun, MM, MT-BC, is a neurologic music therapy mentor and a senior music therapist at The Institute for Rehabilitation and Research (TIRR) in Houston. References 1. American Music Therapy Association. Music Therapy and Medicine. Available at: www.musictherapy.org. Accessed July 15, 2001. 2. Thaut MH. Techniques of neurologic music therapy in neurologic rehabilitation. In: Thaut MH. Training Manual for Neurologic Music Therapy. Fort Collins, Colo: Colorado State University; 1999. 3. McIntosh GC, Thaut MH, Rice RR. Rhythmic auditory stimulation as an entrainment and therapy technique: effects on gait in stroke and Parkinson's patients. In: Pratt RR, Spinge R, eds. Music Medicine. Vol 2. St Louis: MMB; 1996:145-152. 4. Thaut MH, Rice RR, McIntosh GC. Rhythmic facilitation of gait training in hemiparetic stroke rehabilitation. Journal of Neurological Science. 1997;151:207-215. 5. Sparks R, Holland A. Method: melodic intonation therapy for aphasia. Journal of Speech and Hearing Disorders. 1976;41:287-297. 6. Berlyne DE. Aesthetics and Psychobiology. New York: Appleton-Century-Crofts; 1971.
