Music Therapy and Movement with Older Adult Stroke Patients

Every year approximately 800,000 Americans have a stroke, making it one of the most common causes of death (“Stroke,” Centers, 2017, para.1). Strokes typically require invasive treatment and long term recoveries which have a significant impact on the victim as well as their family. Music therapy is more commonly being used along with other medical therapies in stroke recovery. Research shows that music therapy can help improve cognitive processing, language skills, and motor movement.

         A stroke occurs when blood supply to the brain is interrupted. There are two types of strokes: ischemic and hemorrhagic. An ischemic stroke is caused when blood supply to the brain is blocked. This can happen when an artery becomes blocked, particularly in places where the artery narrows. Hemorrhagic strokes occur when a blood vessel ruptures and bleeds into the brain, an example of this would be an aneurysm that ruptures (“Stroke,” Cleveland, 2017, para 2-4). Of the two types of stroke, ischemic is much more common and makes up about 87% of all strokes that occur each year (“Stroke,” Centers, 2017, para. 1).  Common symptoms of a stroke include sudden loss of speech, slurred speech, sudden vision changes, sudden weakness, dizziness or paralysis, and debilitating headache with vomiting (“Stroke,” 2018, para. 2).

 Recovering from a stroke can be very difficult and often requires the patient to go through inpatient rehab. Treatment and recovery time varies from patient to patient, as the part of the brain that suffered the most damage will determine the other areas that suffer. A patient may be paralyzed or experience great weakness on one side. With this comes pain and other sensations like numbness and tingling. Patients often have to go through rigorous physical and occupational therapy to regain lost function. Patients often experience depression and may have trouble controlling their emotions through recovery as they adjust to their new normal (“Stroke,” 2018, para. 9).   

Improved motor activity is a major goal for stroke patients. Gait is often affected after experiencing a stroke. A case study investigated the use of neurologic music therapy (NMT) for gait training in addition to standard practice of care in the inpatient rehabilitation setting following stroke. A 41 year old male who suffered a right middle cerebral artery stroke, rupture of aneurysm caused by an infected thrombus, and uncal herniation was the participant in the study. NMT was used during the first week of physical therapy treatment as an adjunct standard care 2-3 days a week.  The participant went from a 33 on the Functional Independence Measure (FIM) and a 0/56 on the Berg Balance Scale to a 92 on the FIM and a 10/56 on the Berg Balance Scale.This means the participant’s balance increased significantly as well as their ability to function independently and complete activities of daily living. NMT was an integral part of the patient’s gait training (Spaulding & Harris, 2017, p.1). Music has a way of motivating individuals. Gait training requires the patient to be motivated to improve their motor functioning. 

Entrainment is a common music therapy technique used for stroke patients. Entrainment is the synchronization of music to movement. The pulse or tempo of the rhythm is matched with the timing of specific movements. Rhythm provides predictable structure that helps the brain plan movement. Music engages both sides of the brain which may help the brain build new pathways helpful in relearning movement. Music is also a motivator and helps increase endurance. A 2013 study investigated the immediate effect of rhythm on kinematic movement patterns, especially reaching trajectories, variability of movement timing, and elbow range of motion. This study was focused on hemiparetic arm reaching movements of patients with stroke. Elbow range along with both cyclical movement timing and smoothness of reaching trajectories improved significantly (Thaut, 2013, p. 32). Research was conducted on the effect of repetitive rhythmic arm training using a Patterned Sensory Enhancement (PSE) protocol and assessed with the Wolf Motor Function Action Test (WMFT) and the self reporting Motor Activity Log (MAL). The improvements were evident throughout both assessments (Thaut, 2013, p. 32). The positive results of this study speak to the relevance of music therapy as an effective treatment. A third study was conducted using Constraint Induced Therapy (CIT). Trunk flexion and shoulder rotation were compared in a discrete arm reaching versus cyclical reaching task cued by auditory rhythm. Thaut concludes, “The rhythmic cyclical task reduced trunk flexion and increased shoulder and trunk rotation comparable to normal patterns whereas in the discrete task subjects relied mostly on extended forward flexion of the trunk to reach the targets” (2013, p.32). Music therapy uses entrainment as one way to improve motor movement of stroke patients.  

When working on motor functioning, the experience can often be quite painful for patients. Music therapy can aid in managing pain perception. In a study on the effects of music therapy on pain perception of stroke patients during upper extremity joint exercises, positive effects and verbal responses were observed. Ten stroke patients participated in the study where music conditions consisted of either a song, karaoke accompaniment, or no music. Subjects repeated three conditions and rated their perceived pain on a scale immediately following each condition. The subjects played the piano, drums, and rhythm instruments and reacted positively during music therapy treatment sessions. The music therapy sessions helped reduce pain during physical exercises designed to increase the patient's hand function. (Kim & Koh, 2005, p. 1).

         Music therapy is extremely beneficial for those who have suffered from a stroke. Strokes impact many people in a variety of ways so it is crucial to have treatment plans in place. Music therapy is effective in improving the quality of life for those who have experienced a stroke. Research also shows that music therapy improves speech and language skills, cognitive functioning, and motor functioning for stroke patients. It is crucial that research continues and more studies on the use of music therapy take place within the field of medical music therapy and stroke.  

References

Kim, S. J., and Koh, I (2005). "The Effects of Music on Pain Perception of Stroke Patients during Upper Extremity Joint Exercises." Journal of music therapy, 42.1 (2005): 81-92. Retrieved August 12, 2019 from https://search-proquest-com.bunchproxy.idm.oclc.org/docview/1097310?accountid=8570&rfr_id=info%3Axri%2Fsid%3Aprimo

Pfeiffer, C., and Sabe, L. (2015). "Music Therapy and Cognitive Rehabilitation: Screening of Music Cognition in Adult Patients with Right Hemisphere Stroke." Psychomusicology 25.4,  392-403. Retrieved August 12, 2019 from https://search-proquest-com.bunchproxy.idm.oclc.org/docview/1783684326?accountid=8570&rfr_id=info%3Axri%2Fsid%3Aprimo

Spaulding, A., and Harris, B. (2017). “Neurologic Music Therapy for Gait Training Following Stroke: A Case Study.” Archives of Physical Medicine and Rehabilitation, vol. 98, no. 10, Retrieved August 12, 2019 from https://www.sciencedirect.com/search/advanced?docId=10.1016/j.apmr.2017.08.272

“Stroke.” (2017). Centers for Disease Control and Prevention, Centers for Disease Control and Prevention. Retrieved August 12, 2019 from www.cdc.gov/stroke/facts.htm

“Stroke.” (2017). Cleveland Clinic, The Cleveland Clinic Foundation. Retrieved August 12, 2019 from my.clevelandclinic.org/health/diseases/17519-stroke

“Stroke.” (2018). Mayo Clinic, Mayo Foundation for Medical Education and Research, Retrieved August 12, 2019 from www.mayoclinic.org/diseases-conditions/stroke/symptoms-causes/syc-20350113

Thaut, M. H. (2013). "Entrainment and the Motor System." Music Therapy Perspectives, 31.1,  31-34. Retrieved from https://search-proquest-com.bunchproxy.idm.oclc.org/docview/1514320468?accountid=8570&rfr_id=info%3Axri%2Fsid%3Aprimo

Mental Health & Community Music Therapy

According to the Nation Alliance on Mental Health, 1 in 5 adults experience a mental health illness. Current statistics show an increase in those diagnosed with a mental health illness receiving treatment, whether it be through therapy, medication, or a combination of both. While mental health illnesses are becoming prevalent around the world, the health care coverage system continues to make inpatient treatment sessions shorter, but more frequent. Mental health and music therapy, more specifically the Community Music Therapy Model, allows for inclusivity of making music and building relationships with individuals in mental health settings. 

The use of music within the mental health setting not only creates an environment of inclusion, it also affects the neurobiological responses a body produces. Some mental health illnesses can be caused by an imbalance of neurotransmitters or hormones within the brain. One example of music affecting the brain is when calm or relaxing music is played, the body will decrease cortisol levels, creating the response of minimizing stress (Legge, 2015, pg. 128). Music has influenced the release of hormones associated with “social affiliation and trust” (Legge, 2015, pg. 135). This release of neurobiological responses allows for individuals diagnosed with mental health illness to be successful in an environment where Community Music Therapy Model is used. 

The Community Music Therapy Model, also called CoMT, “emphasizes human connectedness, well-being and social change in and through music” (Baker, Jeanneret, & Kelaher, 2017, pg. 158). This value based perspective gives each member of the community a voice in which he/she can express and connect to those around them. This model allows for individuals who may not have access to meaningful music making experiences, the ability to highlight strengths and gain resources for growing relationships and outlets for expression in a community setting. 

CoMT uses interventions, such as lyric analysis, improvisatory music making, or songwriting, to gain perspectives, time for reflection, and processing of emotions with a professional who can direct the responses in a therapeutic and comprehensive way. (Warren, 2016, para 4-7). 

For those in a mental health setting, lyric analysis “introduces a novel and less-threatening approach to process emotions, thoughts, and experiences” (Warren, 2016, para 4). A lyric analysis uses either live or recorded music to allow each client the ability underline or discuss specific lyrics within the song and relate them to experiences they have encountered. 

While playing with various instruments, improvisatory music making creates an environment where socialization and themes can be used for non-verbal communication between individuals attending music therapy (Warren, 2016, para. 5). Music therapists use themes, such as creating an ocean scene, to display tension and release through instrument play. Following the improvisation, a music therapist can lead a discussion about how each person felt during the experience or allow for correlation between instrument playing and life experiences. 

Songwriting, can either be through filling in the blanks to a familiar song or creating a new song from the beginning. The use of songwriting can be “validating, and can aid in building self-worth. This intervention can also instill a sense of pride, as someone listens to their own creation” (Warren, 2016, para 7 ). During the songwriting experience, the music therapist provides a direction for musical and lyrical suggestions. 

The use of a music therapist facilitating a CoMT environment is crucial, instead of someone who works at the facility, as the “success of the facilitation suggest transformation of relationships at different ecological levels, with the facilitator/music therapist creating the conditions and environment for this to occur” (Baker, Jeanneret, & Kelaher, 2017, pg. 159). The CoMT space is most successful when individuals are willing to participate and create music. The participation of those attending music therapy sessions create a safe environment for self-exploration and empowerment through music. 

In conclusion, the Community Music Therapy Model is indicated to be used continue to be used in the mental health setting, as it allows for self expression and relationship building through interventions that increase creativity and group participation. Music therapy and mental health will continue to expand creating environments for more positive growth and experiences. 

-Michaela Shockcor, Music Therapy Intern

References 

Baker, F. A., Jeanneret, N., & Kelaher, M. (2017). Musomagic: Artist-led personal development programmes for youth as viewed through a Community Music Therapy lens. International Journal of Community Music, 10(2), 157-169. doi:10.1386/ijcm.10.2.157_1.

Legge, A. W. (2015). On the neural mechanisms of music therapy in mental health care: Literature review and clinical implications. Music Therapy Perspectives, 33(2), 128-141. Doi: 10.1093/mtp/miv025.

NAMI. (n.d.). Retrieved from https://www.nami.org/learn-more/mental-health-by-the-numbers.

Warren, M. (2016, December 19). NAMI. Retrieved from https://www.nami.org/Blogs/NAMI-Blog/December-2016/The-Impact-of-Music-Therapy-on-Mental-Health.

West, T. (2018, December 04). Wrt1050. Retrieved from https://writingandrhetoricatoaklanduniversity.wordpress.com/author/wrt1050/. 

Older Adults & Therapeutic Singing

We all experience aging, and according to the World Health Organization, “people everywhere are living longer” (World Health Statistics, paragraph 1). Currently, the older adult population has increased life expectancy by about 20 years (World Health Statistics, paragraph 2).  Older Adults may present with a variety of diagnoses, such as those with progressive neurodegenerative disorders, Parkinson’s or Alzheimer’s disease, and respiratory diseases, such as Chronic Obstructive Pulmonary Disease (COPD). However music therapists can use therapeutic techniques, like therapeutic singing, to address any health concerns, open communication, and improve overall well being with those diagnosed.

According to Dassa and Amir, music therapy and group singing creates new ways to increase communication, as therapeutic singing evokes memories, self-expression, and sense of comfort (2014). Groups, such as choir and other musical ensembles, provide an outlet where people can gather and discuss life experiences or struggles that others may encounter.  “Group singing sessions that focused on singing and reminiscing have been found to be significantly helpful in reducing symptoms of depression…” (Dassa & Amir, 2014, pg. 134) and can promote activities of daily living, such as swallowing and respiratory control (Stegmoller, 2017, pg. 408). 

Therapeutic singing displays the most benefits when it occurs in a large space that is familiar to those attending. The intervention of singing begins with breathing exercises, and is followed by “3 to 5 songs selected from a list of participant- chosen music selections” ( Elefant, 2012, pg. 285) Due to the educational training and certification a music therapist must receive to provide appropriate services, items such as client preferred music, tempo, therapeutic techniques for discussion,and musical cues for breathing become more effective, than someone who might sing recreationally to increase socialization between older adults.  

Group singing led by a music therapist, creates an environment where memories can be evoked through music familiar to each individual attending. Client preferred music, such as music from adolescence or early twenties, promotes “well-being and sense of self” (Dassa & Amir, 2014, pg. 145). Not only does listening and conversing about preferred music increase reminiscence, vocal warm ups allow for concentration to be placed on articulation and oral muscle movement. Vocal warm ups before singing, “target specific therapeutic needs of the Parkinson’s disease population” (Stegmoller, 2017, pg. 411).

  The repetition of familiar songs generates an “increase in participation and promotes security” (Lesta & Petocz, 2006, pg. 9), as well as “imitation and modeling to support” (pg. 9) responses provided in a group setting. Specifically singing has the ability to connect and provide power to those with Alzheimer’s and Parkinson’s disease. Singing familiar songs administers a group dynamic, even with those diagnosed in the middle stages of their progressive disorder (pg. 6) The ability to be within a group of individuals experiencing similar interactions, acknowledges the understanding of social support and connections through peer interactions (pg. 7)

Music therapists have used therapeutic singing with songs like “She'll Be Coming Around the Mountain” with older adults to create an environment where isolation dissipates. During this intervention, the music therapist may ask one client to name a place that they have visited and then the new lyrics will be filled into the song. Once the song has been sung, the music therapist will ask if anyone in the group has visited the place and items they remembered while visiting there. This technique of asking others attending the group, allows for a connection between patients to begin and conversations to continue following music therapy. 

In conclusion, group singing creates an environment that allows for music therapy techniques of reminiscence and self-expression to be evoked in most individuals through client preferred music. Music therapy and group singing allows for older adults to feel connected to the people around them.

-Michaela Shockcor, Music Therapy Intern

Resources

Alzheimer’s Association. (n.d.). What is Alzheimer’s? Retrieved from 

https://www.alz.org/alzheimers-dementia/what-is-alzheimers

COPD: Everything you need to know about chronic obstructive pulmonary disease: Everyday health. (2019, July 01). Retrieved from https://www.everydayhealth.com/copd/guide/

Dassa, A., & Amir, D. (2014). The role of singing familiar songs in encouraging conversation among people with middle to late stage alzheimer’s disease. Journal of Music Therapy, 51(2), 131-153. Doi: 10.1093/jmt/thu007

Elefant, C., Baker, F. A., Lotan, M., Lagesen, S. K., & Skeie, G. O. (2012). The effect of group music therapy on mood, speech, and singing in individuals with Parkinson’s disease- A feasibility study. Journal of Music Therapy, 49(3), 278-302. doi: 10.1093/jmt/49.3.278

Heyn, S. N.,& Davis, C. P. (n.d.). Parkinson’s Disease Early and Later Symptoms, 5 Stages, and Prognosis. Retrieved from https://www.medicinenet.com/parkinsons_disease/article.htm

Lesta, B., & Petocz, P. (2006). Familiar group singing: Addressing mood and social behavior of residents with dementia displaying sundowning. Australia Journal of Music Therapy, 17, 2-17. 

Stegmoller, E. L., Hurt, T. R., O’Connor, M. C., Camp, R. D., Green, C. W., Pattee, J. C., & Williams, E. K. (2017). Experiences of persons with parkinson’s disease engaged in group therapeutic singing. Journal of Music Therapy, 54(4), 405-431. Doi: 10. 1093/jmt/thx012

World Health Statistics 2014. (2014, May 15). Retrieved from https://www.who.int/mediacentre/news/releases/2014/world-health-statistics-2014/en/

social stories

The term Autism Spectrum Disorder “refers to a broad range of conditions characterized by challenges with social skills, repetitive behaviors, speech and nonverbal communication” that affects approximately 1 in 59 children in the United States (Autism Speaks, n.d.). Signs of the disorder begin to appear around the age of 3 but may be present as early as 18 months.  As a spectrum disorder, Autism presents itself in many ways. The two most common symptoms of Autism are: 1. interpersonal challenges such as difficulty recognizing/interpreting emotions and eye contact and 2. restricted and repetitive behaviors like hand flapping and rocking (Autism Speaks, n.d.). The cause of Autism is unknown. Environmental factors such as birth related complications may increase risk but research shows that there are both genetic and environmental components that factor into the Autism diagnosis. (Autism Speaks, n.d.). 

In 2015, the National Autism Center named music therapy as an “emerging intervention” for Autism treatment (AMTA Strategic Priority Group). Common goals include improvement of language/communication, behavioral/psychosocial, cognitive, perceptual, and motor skills (Autism Spectrum Disorders, 2010). Music therapy goals are based on an assessment that measures a client’s strengths, weaknesses, and preferences while considering the family’s priorities. The assessment is used to measure a client’s baseline through musical interventions and then develop a treatment plan (AMTA Strategic Priority Group, 2015). 

Music interventions like instrument play help to improve social skills and interpersonal interactions. Other common interventions include songwriting and lyric analysis. These interventions help with idea development and creativity (Autism Spectrum Disorders, 2010). Research shows that music therapy helps improve communication, attention span, fine and gross motor skills, interpersonal skills, responsibility, emotional expression, and play.

Musical social stories can also help change behaviors and teach new skills (AMTA Strategic Priority Group, 2015). A social story is a short story that plainly states the steps of an activity or a target behavior. It may also tell relevant information such as who, what, when, or where an activity takes place (Brownell, 2002, p.121). Social stories may be a task analysis of a specific activity like brushing teeth or an activity schedule that goes through the steps of a morning routine (Schwartzberg & Silverman 2013, p. 331). The first step to creating a social story is identifying a goal or target behavior and measuring the baseline. Once a goal is established and data has been collected, a story can be written using “descriptive, directive, perspective, and control” sentences (Brownell, 2002, p. 122). Social stories can then be implemented in music therapy sessions to address target behaviors.

The following is an example of a musical social story:

Music therapy is able to use social stories and can “lead to improved comprehension and generalization of targeted social skills (Schwartzberg & Silverman, 2013, p. 334).When a story is presented to a client it is best to have between one and three sentences on each page with a picture. As the story is read to the client, demonstrate the appropriate behaviors and prompt the client to follow along (Brownell, 2002, p.123). Social stories can be read like a book or sung like a song. When creating a new social story, the lyrics and tune can be original or they can be written “piggyback” style where the therapist selects a familiar, memorable tune and creates new words. Brownell’s research found that when read, social stories increased target behaviors such as appropriate greetings and parallel play and decreased undesirable behaviors such as aggression. This research found that when sung, social stories increased target behaviors at an even higher rate (2002, p.121). Schwartzberg and Silverman’s study found anecdotal evidence that music based social stories were “enjoyable,” “catchy,” and transferable to daily life (2013, p. 334). 

In closing, music therapy uses social stories to address goals such as communication, behavior, and cognitive skills. Social stories teach behaviors or new skills that can be used at home or school to prompt desired behaviors. Musical social stories are set to an easily singable tune. This musical quality makes the social story memorable and transferable to other settings which helps the client be successful in and out of music therapy.


-Rachel Buchheit, Music Therapy Intern

References

AMTA Strategic Priority Group. (2015, August 26). Fact sheet: music therapy and Autism Spectrum Disorder (ASD). American Music Therapy Association. Retrieved from https://www.musictherapy.org/assets/1/7/Fact_Sheet_ASD_and_MT__8-26-15.pdf

Autism Speaks. (n.d.).What is Autism? Retrieved June 26, 2019, from https://www.autismspeaks.org/

Autism Spectrum Disorders: Music therapy research and evidence based practice support. (2010). American Music Therapy Association. Retrieved from

https://www.musictherapy.org/assets/1/7/bib_autism10.pdf

Brownell, M. (2002). Musically Adapted Social Stories to Modify Behaviors in Students with Autism: Four Case Studies. Journal of Music Therapy, 39(2), 117-144.

Schwartzberg, & Silverman. (2013). Effects of music-based social stories on comprehension and generalization of social skills in children with autism spectrum disorders: A randomized effectiveness study. The Arts in Psychotherapy,40(3), 331-337.

Meet Ms. Michaela!

Hello! My name is Michaela Shockcor and I am thrilled to be joining the Therabeat team as a music therapy intern. I am from Columbus, OH and recently finished my academic course work at Ohio University. Some of you may be wondering why a new college graduate packed up and moved her life 10 hours away, and here’s the reason why. While at Ohio University, I worked with multiple populations, but always felt my heart belonged working with children and adolescents. For the past few summers, I have been a teacher's aid to a transition classroom and enjoyed every minute of my experience there. When an intensive search began for various music therapy internships, a professor recommended that I contact the Therabeat team. So, I did and thoroughly enjoyed everything this program had to offer. From advocacy to music recitals, Therabeat will allow me to form my personal music therapy style and voice, as well as become a well rounded individual with all of the lessons I will learn

Amid my first week here, I have felt welcomed by everyone I have met and it’s just the beginning! From observing occupational, physical, and speech therapy to meeting everyone during music therapy, I am forming new relationships and learning so much. The various teaching styles each therapist bring to their sessions has allowed for new techniques and a greater understanding of why we do what we do. To learn from a teacher is wonderful, but to learn things from a child is even better. During internship, I hope to gain a greater love for music and working with children and adolescents, as well as immense growth in my music therapy skills and techniques. I am someone who is always willing to push myself in new opportunities, in order to become better than I was before.

I can tell that Therabeat and In Harmony Pediatric Therapy will keep my on my toes with new adventures and opportunities each and every day!

-Michaela Shockcor, Music Therapy Intern