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Reframing rehab through the arts

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The arts therapies and neurologic music therapy (NMT) in particular can work seamlessly towards a rehab programme’s shared functional goals.

They also help to overcome the psychological blocks which may prevent 
a person fully engaging in rehab. A recent Cochrane Review (2017) found that “music interventions using rhythm may be beneficial for improving walking in people with stroke”.

It also noted “treatment delivered by a trained music therapist might be more effective than treatment delivered by other professionals”.

Daniel Thomas, of arts therapies provider Chroma, says: “Working across both the functional and psychological aspects
of a person’s rehabilitation towards 
shared goals is how the arts therapies optimise outcomes.

“Enabling the patient to re-frame their relationship with their own rehab also makes arts therapies such an effective tool within the multi-disciplinary team.”

Here Daniel answers our questions on the rise of arts therapies and their potential value to neuro-rehab professionals and their clients:

What are the arts therapies, are they regulated and who are they for?

They are a group of three distinct professions – art psychotherapy, dramatherapy and music therapy.

They are regulated by HCPC and are an allied health profession. Current training is based at MA level and includes medical studies, neuroscience, attachment, creating research, psychological models and assessment.

Job titles, such as music therapist, are protected in law and there are around 4,000 UK arts therapists.

Our organisation provides all three arts therapies across the UK to partners in the education, health and social care sectors.

Our therapists work with people of all ages and stages of life, from pre-term babies in NICU units, to adults and children with brain injuries and other neurological conditions, to families supporting an elderly relative within a palliative care setting.

What conditions do they work with?

The wide range of conditions treated by the arts therapies includes acquired and traumatic brain injuries (ABI/TBI), other neurological conditions, autism, mental health, stroke, dementia, learning difficulties, cerebral palsy, attachment and family issues, disordered eating and bereavement.

The arts therapies can facilitate the attainment of functional goals, for example gross/ ne motor skills within a neuro-rehab setting, while also working with the same patient to address some of the psychological barriers to their engagement with rehab, such as anger, hopelessness or depression.

Is there any evidence for the arts therapies?

There are thousands of published articles, papers, case studies, books and pieces of practice-based evidence to support the efficacy of the arts therapies.

There are a handful of RCT based
 studies too, but it’s often not a very 
helpful way to judge the effectiveness of the arts therapies.

By their very nature, they are a highly personalised form of non-pharmacological medication without side effects which should be facilitated by a trained professional.

Over the past few years there have been a number of positive Cochrane Reviews, including the 2017 review looking at ABI.

Within NMT, there are hundreds of published papers and research studies – it is the most comprehensively researched and evidence-based form of music therapy.

How did NMT emerge as a distinct approach?

About 20 years ago, neuroscience researchers started looking at music perception in the brain.

They began to see how the brain was impacted and changed by music, for example when we hear music with a strong regular beat.

When this happens, our auditory neurons interact with our motor neurons to produce a regular pattern of motor-neural ring, based on the musical pulse. This in turn allows us to tap our toes in time with the music.

Researchers started to see there were many more of these “automatic” processes that occur in a brain stimulated by music that could be used within neuro-rehab.

Dr Michael Thaut, who developed the 
NMT model alongside clinicians such as 
Dr Corene Thaut and Sarah Johnson, realised that by stimulating motor neurons with a regular auditory pulse, gait patterns in people with Parkinson’s became more symmetrical (Arias & Cudeiro 2008 / Bukowska et al 2015).

It’s easy to see this ‘disco effect’ in action – just notice what happens to your body when you hear music with a regular beat or, when jogging, how you tend to run to the beat or speed of the music.

This finding then led to other discoveries and the NMT model, with its 20 approved techniques, was born in the late 1990s.

Much of the research (over 200+ published articles) has been published
 in academic journals and proceedings, and much of it can be found via the NMT Academy website (www.nmtacademy.co).

How exactly can NMT optimise outcomes in neuro-rehab?

NMT is so effective within neuro-rehab because it utilises many of the automatic and
in-built ways that a brain responds to music.

Music therapists who have completed
 the additional neurologic music therapy training, and who are certified and registered with the NMT Academy, work towards shared treatment goals.

These cover the sensorimotor, cognitive 
and speech and language domains.
 One of Chroma’s NMTs will work closely with the MDT or case manager to understand what the shared treatment goals are, and work towards these.

It is by tapping into what neuroscience has told us about music and the brain that we are able to support neuroplasticity and re-wire or reconfigure neural pathways via engagement with music.

A simple example would be someone whose language ability has been damaged in an accident or a stroke.

Because they now find it impossible to remember the words they need, we can reteach functional everyday phrases through song. The known melody acts as scaffolding, from which the new phrases and words can be hung.

The tune from Twinkle Twinkle Little Star helps the client recall the phrase “Can I have a cup of tea” for example.

If a client already has physiotherapy, why bring in NMT?

Using music as a context for physiotherapy can re-engage a client in the process. This may be useful if a client needs re-motivating around their rehab.

For many clients, it is the way that NMT helps to re-frame their relationship to their own rehab that is so important.

We had a recent case where a child was having gait training, but was frustrated and upset with the pain of the exercises and also at the repetitive nature of what the physio was requiring.

He was actually only being compliant and engaging for about five minutes a session. One of our NMTs started to work 
alongside the physiotherapist and toward her goals.

The NMT designed a few musical interventions that helped the child to complete the required physio movements, but engaged him in an exciting musical dialogue.

He was able to bring playfulness into his physio sessions, and his dad loved seeing his son show some of his playful nature again.

In terms of the hard outcomes, the child’s step cadence went from 21 steps/minute to 56 s/m in less than three weeks.

We also have adult clients who increase the number of required movements from five per five minutes to 18 per five minutes as
 a result of including NMT within their rehab programme.

Re-contextualising rehab so that the client has a new positive relationship with it is ultimately what NMT allows to happen.

What about clients who are stuck and won’t engage with rehab? Can arts therapies work with them?

There are all sorts of reasons why clients struggle to engage. Some will be practical, and a big part of NMT is reframing the rehab in a more creative and engaging way.

But it is really important not to forget the psychological impact of loss and change, and this is an area the arts therapies work particularly well with.

Arts therapists have a background in emotional and mental health and will bring a real understanding of both the conscious and unconscious processes that can leave a client feeling stuck, demotivated and hopeless. Working creatively to address these feelings can help clients move through these issues.

This might be through song writing in music therapy, through the art work created in art therapy or through story or characters in dramatherapy.

What can really help is the distance provided by creativity.
 A dramatherapist might enable a client to create a story into which they project their experiences and feelings.

But because it is not about them directly, it is a story, they can manage and explore the feelings in a much more manageable way.

And through creating a story they can explore other options and possibilities that might feel impossible when thinking directly about themselves and their current situation.

For more info on arts therapies in neuro-rehab settings, contact Daniel Thomas of Chroma via daniel@wearechroma.com or 0330 440 1838. www.wearechroma.com.

 

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News

Askham enables families’ voices to be heard

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Relatives of those with brain injuries can now spend time with therapists to aid their discharge through Askham

Families are being enabled to regain their voice in the care and rehabilitation of their loved ones through the creation of a new forum at a specialist Cambridgeshire community.

An ‘Ask the Therapist’ forum has been introduced by Askham Rehab, part of Askham Village Community, to help bridge the gap created by lockdown between relatives and therapists.

Through monthly video calls, families of Askham residents with complex brain injuries can receive support and advice from the community’s multidisciplinary team, alongside updates on their loved one’s treatment and pathway.

The sessions rotate between therapists specialising in the neurological fields of psychology, physiotherapy, occupational therapy, and speech and language.

The aim is to allow the relatives to spend time with all four therapist teams to build rapports and reassurance, and gain the knowledge needed in preparation for their loved ones’ discharge.

Askham say the sessions were created to help support the mental health of residents during times when they cannot interact with their loved ones and their therapy team as usual.

“When the pandemic came, we soon realised we had lost the voice of our relatives. While they were still calling in or contacting us via email, we lost the daily 1-on-1 conversations they had with our therapists,” says Priscilla Masvipurwa, Chair of the Askham Rehab Quality Improvement Board.

“We decided we needed a forum where relatives could be part of an informal setting and seek advice on brain injuries with our therapists. By having a group, the relatives had the chance to meet with others who were going through very similar journeys.

“It created a confidential space where they could learn from and support each other.”

While rehabilitation support continues to be provided to residents as usual, Priscilla says the team were mindful of the need to extend emotional support to relatives during such difficult circumstances.

“The initial idea was to actually offer teaching sessions, but we quickly realised that would just close people off from expressing their concerns and struggles,” she says.

“Ask the Therapist has created a place where people experiencing the same circumstances can advise each other on how they are coping. It has turned into a productive space where educational and emotional support is given.

“Relatives just want someone to talk to. Sometimes they aren’t even on the radar of therapists and we didn’t want that happening at Askham.

“Ask the Therapist allows us to reach out to the relatives and if any of them need more support we can assess that in the informal meetings and signpost or initiate some kind of therapy outside of the sessions.”

The success of the lockdown-inspired initiative has led to wider discussions to potentially have people who have received treatment at Askham to take part in future sessions to impart their experience to others going through the same journey.

“The positive feedback has been overwhelming, and has led to possible plans to open the session up to the wider community in the near future,” adds Priscilla.

“We’re grateful to be able to offer this service to our users and I’d like to encourage others to explore wellbeing schemes that allow people to seek out help and support, especially during these mentally challenging times.”

Aliyyah-Begum Nasser, Director at Askham, concludes: “As a family business with for over 30 years’ experience, we truly understand the value and power of family relationships and are keen to ensure that our patients can channel the strength and support of their families into helping them fulfil their rehab potential.”

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Music therapy enables rehab to transcend boundaries

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People living with brain injuries across the UK and Ireland are being brought together by a music therapy programme, which has delivered proven results in rehabilitation.

From its base in London, Connect Music Therapy has traditionally held its sessions in-person in people’s homes, but more recently launched an online offering which is enabling its reach to be significantly extended.

Founder Janina Brady, who also travels to her native Ireland to hold sessions, had adapted her business to enable her to reach greater numbers simultaneously, as well as allowing her to hold one-to-one sessions beyond Connect’s usual geographical reach in the UK.

Janina, who began teaching music in 2010, set up Connect in 2018 and supports people with a range of disabilities and additional needs.

She works widely with people with brain injuries and neurological conditions in enabling them to access the physical, cognitive, emotional and communication benefits music therapy can deliver.

“Music can deliver benefits in so many different ways and can be so important in day to day life,” says Janina, who holds a Masters in music therapy.

“We work with people for the long-term and can see the positive impact it has on them over a developing period of time. I’m continually blown away by the responses we get and how people respond to it.

“When you look at a scan of how a brain responds when music is played, it lights up like a Christmas tree, there is nothing else that stimulates like that. And by stimulating parts of the brain that have not been damaged by their injury or condition, we are helping to create new pathways.

“And when you see the effect that has on the person, the joy it beings out and the progress they are making, it makes this the most wonderful, rewarding work.”

Although sessions had been in-person since Connect was established, the COVID-19 pandemic meant that was no longer possible. But realising the importance of the continuity and positive impact on her clients, Janina took her sessions online from the beginning of lockdown.

“As we work with our clients over a long period of time, music becomes part of their lives, so I realised the need for that to continue. Clients have responded so well to the sessions moving online, and one very nice aspect of that is that so many family members or carers have become more involved in their sessions,” says Janina.

“It has been great in enabling us to bring people together much more widely that we’d ever have done prior to the pandemic. By creating a group which involves people from London and elsewhere in the country alongside people from Ireland, we are developing a community.

“Music is such a bridge for people, it connects everyone in some way.”

Music therapy can take different forms for people, depending on their unique circumstances and needs.

“We can adapt that we do to whatever their capability is, whether that’s communicating through blinking or nodding, or whether that is by banging a drum with their foot,” says Janina.

“We use a variety of approaches depending on the needs of the person. As one example, we often use musical markers throughout the day, through the use of special songs to associate with a morning routine, waiting for the bus, whatever it might be. By effectively creating a musical timetable, we are helping to create structure for people’s days.

“But while everyone’s needs are different, we are working across the board to promote wellbeing and to focus on what our clients can do, rather than what they can’t. We focus on the positives and on seeing our clients at their best.”

While remote sessions may not have been something considered pre-pandemic, they have proven their worth over the past few months, adds Janina.

“In many ways, sitting in front of a screen has similarities to me being there. I can still be in front of my clients, and hold things up for them to choose from and I can see their reaction of blinking or nodding, so it has been able to work,” she says.

“Online sessions have shown to be a good alternative. For example, in situations going forward where I have a client on immune suppressants and I can’t visit, we could look to do a session online. And when I went to Ireland at Christmas I had to isolate for 14 days, I could do my sessions remotely as usual, irrespective of where I was.

“And since the first lockdown, we have adapted even more in terms of adding more microphones and equipment, so we’re all set up for going forward. I can’t wait to get back to seeing clients face to face, but remote sessions will have their place alongside that.”

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Case management

“I had to recover from life-saving neuro surgery during lockdown”

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Lee Atkinson

Having had a subarachnoid haemorrhage the day after full lockdown was imposed on the UK in March, Lee Atkinson faced the trauma of a lengthy recovery without seeing his family. Here, he shares his story of how he coped.

For millions of people across the country, the onset of the COVID-19 pandemic marked the start of a hugely challenging period. But for Lee Atkinson, that challenge was one of survival, after he experienced a subarachnoid haemorrhage the day after the UK went into lockdown on March 23.

Having felt unwell for about three weeks, Lee, a car garage manager, was seeking medical attention for his developing situation.

“He had been coming home from work feeling really tired and he’d had a few headaches,” recalls his wife, Petra.

“He went to the GP and they thought it was down to high blood pressure. He was even seen at the hospital for a scan and then he went back to work.

“But then I came home one morning after a night shift and found him collapsed in the bathroom.”

Lee, 47, was rushed to the Royal Preston Hospital, and underwent life-saving surgery after it was established he had experienced a haemorrhage. In the aftermath of his operation, Lee realised he had become partially paralysed and was struggling to communicate.

As the pandemic escalated, Lee was transferred out of hospital and into the Sue Ryder Neurological Care Centre Lancashire. The purpose-built centre had only recently opened its doors after an 18-month construction project to bring it to life, and fast-tracked its ability to welcome patients to help relieve pressure on the hospital and other local partners.

“I went into Sue Ryder on a stretcher on April 30, and at that point I was paralysed on my left hand side and my speech wasn’t great. I couldn’t use my left arm,” remembers Lee, a father of two.

“But over a period of time, they helped me get back on my feet, but they were very cautious with me.

“I had a set timetable over the week so everything was planned for me. It was really good for me to have that structure because I was in a bad place to start with. I was quite depressed but they really helped me through that.

“I was wanting to push to walk and they were being cautious because I had a period where I still had a hole in my skull from the operation. They leave it like that for about three months and you have to wear a helmet.

“I still have that helmet – all the Sue Ryder staff signed it for me. We really appreciate what they did. I was really lucky to be moved there.”

Due to the stringent restrictions on visiting imposed as a result of COVID-19, Petra was only allowed to visit her husband once in hospital, and with the pandemic escalating quickly, the opportunity for in-person visits was not possible at Sue Ryder, to protect the centre and its residents from the deadly virus.

However, keen to offer families the opportunity to be together however possible, visiting ‘of sorts’ was enabled by the team.

“After a week or so they let me and the kids go and visit him through the window, just to be able to do that meant a lot to us because we had not seen him for so long,” says Petra.

“Then, after a little while, Lee got better with his phone and was able to Facetime us. The staff were always happy to help with anything like that.

“It was obviously all new for the staff too, because usually the families would be really involved in someone’s care, but because of COVID, we weren’t able to be there.”

But while Lee was parted from his family, he was making strong progress in his recovery, buoyed by the thought of going home and working with the centre’s occupational therapy team to make that happen.

“We really didn’t know if he was going to walk again but the physio team were fantastic and some of the assistants who helped with the cognitive treatment were great,” recalls Petra.

“The staff really catered to his needs. They were so understanding about what he liked to eat and let him eat when he wanted to. They even got him involved in some games. They were just fantastic.”

On August 28, five long months after Lee’s life-saving surgery, he was able to return home, with the assistance of the Sue Ryder occupational therapy team. He is now supported by the local community team for ongoing rehabilitation.

“They arranged for Lee to have an overnight stay before he was discharged so we could make sure everything was in place that we needed,” recalls Petra.

“I went and picked him up and it gave me a chance to talk to them about things I was worried about. It really has changed our lives. It has changed everything. We were just a normal family before this.”

Lee’s recovery continues, but he is grateful for the support of the team at Sue Ryder Neurological Care Centre Lancashire during such a traumatic time for him, and particularly without the ability to see his family.

“I found it really helpful at Sue Ryder because while I was going through a really stressful time in my life, they were really great helping me to get through it,” adds Lee.

“I was just lucky that they were able to open when they did.”

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