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Why music therapy is striking a chord in neuro-rehab

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 A major new review, due imminently, is expected to show further hard evidence of the measurable impact of the practice on brain injury clients.

The Cochrane body, which provides systematic reviews for healthcare by expertly scrutinising global evidence, is returning to a topic it last visited in 2010.

That this most authoritative source of evidence for healthcare interventions focused on music therapy and acquired brain injury (ABI) six years ago was a big step forward for the profession in itself.

Back then the review concluded that the music therapy method, rhythmic auditory stimulation (RAS), may be beneficial for gait improvement in people with stroke.

Julian O’Kelly, an honorary research fellow in music therapy at the Royal Hospital of Neuro- Disability, explains the method: “The music therapist may encourage their client to walk to the downbeat rhythm of a guitar, engaging with our natural tendency to coordinate movement to rhythm.

“This can be done with other actions, such as a stretching exercise – perhaps reaching up as you would to open a cupboard.”

Alongside RAS, the Cochrane review referenced other methods and encouraging studies linked to upper extremity function, speech, agitation and cognitive orientation.

But many trials failed to meet Cochrane’s strict data inclusion rules, prompting it to call for more robust studies 
in relation to various outcomes in future.

A separate Cochrane report on music therapy and depression similarly said that, while music therapy is associated with improvements in mood, high quality trials were needed to be confident about its effectiveness.

The new Cochrane report on music interventions for ABI has been expanded
 with many new studies included and reports on a greater number of behavioural domains beyond gait.

It also now includes studies on music interventions as well as those on
 music therapy.
 Such validation is exactly what music
therapy needs, says O’Kelly, who specialises in working with brain injury
clients amongst others.

“Music therapy has really come on in leaps and bounds in the last 10 years and we now have Cochrane reviews on music
 therapy and its use with people with autism, dementia, mental illness as well as brain injury.”

More unequivocal proof of the impact
 of music therapy looks likely, with
 further investment promised by UK
 health authorities.

The National Institute for Health Research (NIHR) recently awarded £200,000 in funds 
to support a global trial on autism and
music therapy led by Anglia Ruskin University.

O’Kelly, meanwhile, is involved in an NHS-funded trial on music therapy and
 chronic depression.

“This is the first time the NHS has invested significantly in music therapy research, which 
is a good sign,” he says.

“Music therapy needs this injection of cash to continue developing its growing evidence base.”

Music therapy’s ability to help the brain rewire and reorganise itself is manifested in an array of different approaches.

One of the clearest examples of music’s link to neuroplasticity is melodic intonation therapy, which combines singing of everyday phrases with rhythmic activity to ‘hijack’ the brain’s natural a affinity
 for linking rhythm, speech and melody.

When scientists at Harvard explored the effects of this technique with neuro-imaging technology, they discovered important changes in the size and strength of brain circuitry linking areas crucial for speech.

As music therapy becomes more accepted
 in neuro-rehab and wider healthcare circles, demand will undoubtedly grow among families and loved ones of brain injury clients.

The profession’s public profile is certainly greater now than it has ever been – thanks in part to mainstream TV and film coverage of the amazing things music does to the brain.

The 2014 documentary Alive Inside shared
 with the world the dramatic impact of enabling people with Alzheimer’s to listen to songs from their youth.

A series of clips, since viewed by millions of people online, showed otherwise detached, incoherent care home residents suddenly singing and dancing with gusto. Long-lost memories came flooding back as they listened to the soundtrack of their formative years.

Such methods come with a note of caution from O’Kelly, however.

“The use of recorded music in an unsupervised way could actually be dangerous for those with Alzheimer’s and other conditions who lack a healthy person’s ability to control their sound environment. Input from a music therapist is advisable with recorded music programmes to avoid taking people on emotional rollercoasters they might be defenceless against,” he says.

But like Alive Inside, the case of Gabby Giffords in America has also shown the YouTube generation the power of music on the brain. Congresswoman Giffords was famously shot in 2011, taking a bullet to the brain which left her in a critical condition.

With her language pathways damaged, words had left her – until a music therapist intervened and gave them back to her, using melody and rhythm. The world watched in awe as a seemingly lost cause battled back from the brink, with music therapy at the heart of her recovery.

Although keen to underline the “evidence-based, clinical” value of music therapy, O’Kelly has his own inspiring moments which highlight music’s seemingly otherworldly power to heal and transform.

“I had one amazing experience with a man with a profound speech difficulty, or aphasia, which meant his words came out, but in the wrong order, as a result of a brain tumour. I knew he was a West Ham FC fan so I sat down at the piano and started to play their song, ‘I’m Forever Blowing Bubbles’. This man who couldn’t finish a sentence was suddenly able to sing the whole song word for word.

“It was transformative because it gave him confidence and hope and made him more receptive to speech therapy. It had a profound effect on both of us.”

There are no doubt many more such stories among the UK’s population of around 1,000 registered music therapists. But, as O’Kelly points out, the profession must move away from a misconception that music therapy is some intangible, albeit powerful, entity.

“If the profession is to develop it really needs to continue doing evidence-based research. There’s a tendency to think music is this nebulous thing that we can’t harness or measure. But that’s wrong. You can measure the effect on an EEG. You can use technology to measure the change in people’s moods; you can pinpoint changes and quantify the effect of music. An EEG can show how music therapy has changed the way a patient’s brain is wired.”

O’Kelly, who has been in music therapy since 1998 after training at the University of Bristol, currently helps people with severe brain injuries, as well as other conditions.

“Often after a serious car crash or major stroke, it can be very hard to differentiate between a vegetative and conscious state. This is where the emotional power of music therapy really comes into its own because it doesn’t require word processing. We can still elicit emotional responses. When it’s difficult to define whether someone is aware or not, music has the ability to change brain pattern, respiration and
 heart rate.”

Several characteristics of music make it applicable to neuro-rehab, says O’Kelly. “Emotionally, it makes us want to move and sing and it brings back memories. It’s like a workout for the brain – and there is an inclination to do it again and again. When someone learns an instrument there is clear evidence of neuroplasticity.

“If you put these factors into the context of
 a brain injury, whether its affecting speech, movement or mood, music is bound to support neuroplasticity.”

Links between music and improved cognitive function are well evidenced. One stand-out study by Dr Teppo Särkämö in 2008 aimed to determine whether everyday music listening could facilitate the recovery of cognitive functions and mood after stroke.

In the acute recovery phase, 60 patients with a le or right hemisphere middle cerebral artery (MCA) stroke were randomly assigned to a music, language or control group.

During the following two months, the music and language groups listened daily to self-selected music or audio books, respectively, while the control group received no listening material.

All patients underwent an extensive neuropsychological assessment, including a wide range of cognitive tests as well as mood and quality of life questionnaires at various stages.

Results showed that recovery in the domains of verbal memory and focused attention improved significantly more in the music group than in the language and control groups.

The music group also experienced less depressed and confused mood than the control group.

What’s more, neuroimaging of the participants showed clear signs of neuroplasticity supporting these improvements for the music group in the form of changes in brain structures.

In the neuro-rehab world, music therapy is increasingly being used to help tackle brain injury-related depression.

“Depression often goes hand in hand with brain injury. Studies have shown that improvising with trained music therapists and talking about the moods the music evokes can improve an individual’s mood,” explains O’Kelly.

Anecdotally, he says music therapists are becoming evermore frequent visitors to brain injury units, working closely with their fellow healthcare professionals.

“They are able 
to converse with occupational therapists, doctors and nurses, and understand clinical observations. They’ll work closely with other professionals in many ways. For example,
we could be carrying out our work, while a doctor observes the client’s reactions
 and responses.

“We can also set homework exercises and teach carers or family members how to practice them. There are also more ways to access music therapy now, with charities and private organisations providing services that were traditionally offered by the NHS.”


A profession in high demand

 The inclusion of music therapy in neuro-rehab is on the increase, reports Catherine Watkins, director of Attune Music therapy (pictured).

“Music therapy providers are increasingly receiving enquiries from brain injury case managers and other professionals working with brain injury survivors,” she says.

“We’re also seeing more demand directly from private neuro-rehab care providers’ units.”

She has also witnessed a shift in the way
 music therapy is being relied upon within neuro-rehab settings.

“Music therapy in the past may have been provided on an ad hoc basis to neuro-rehab facilities but this is changing as more and more recognise the evidence behind our work and the results we can deliver with some of the most complex and hard-to-reach clients.”

Watkins, whose company works with people of all ages with a range of disabilities and challenges, believes attitudes towards music therapy are also changing.

“Music therapy is definitely moving higher up the agenda within neuro-rehab but more education is needed about the many benefits our profession brings. There can be a misconception that music therapy is merely a form of entertainment or just a fun activity for clients.

“It is only when you start talking to people about both psychological and functional rehabilitation that they start to understand the difference.

“Music therapy is an HCPC-regulated profession. Music therapists are not only highly skilled musicians but are trained clinicians who understand and work with a full range
 of disabilities as part of multi-disciplinary teams.

“Its influence within the neuro-rehab arena is only going to continue to grow and generate more interest as the science of music and the brain evolves and professionals and the public both hear and see more of what we can offer.”

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Mobility after stroke – what options exist?

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There are more than 100,000 new incidences of strokes in the UK each year – that is around one stroke every five minutes.

1.2 million people in the UK live with the after effects of stroke every day, making stroke one of the most resource-intensive indications faced by the NHS today, and a huge challenge for many years to come.

The NHS and social care costs of stroke are around £1.7 billion a year in England. Therefore, stroke inevitably demands medical and therapy solutions founded on sound scientific principles, such as those provided by Ottobock.

The National Institute for Health and Care Excellence (NICE) released the Stroke Rehabilitation in Adults [CG162] guidelines, in June 2013.

The guidelines advise the consideration of ankle–foot orthoses (AFOs) for people who have difficulty with swing-phase foot clearance after stroke (for example, tripping and falling) and/or stance-phase control (for example, knee and ankle collapse or knee hyper-extensions) that affects walking.

The treating orthotist will assess the ability of the person with stroke to put on the AFO or ensure they have the support needed to do so and the effectiveness of the AFO for the person with stroke, in terms of comfort, speed and ease of walking. 

For those recovering from a stroke, the right rehabilitation aids – be that orthosis or electrostimulation – depend on the nature of their impairments, as well as their daily activities. The solutions selected will be tailored to their changing requirements over the course of their rehabilitation.

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Hemiplegia – the loss of sensory and motor function on one side of the body – is often the greatest challenge faced by patients following their stroke. This occurs as a result of damage to the central nervous system. Stroke is a leading cause of disability in the UK – almost two thirds of stroke survivors leave hospital with a disability.

Mobility aids that are tailored to each stage of rehabilitation can substantially ease activities of daily living and promote mobility. Limb weakness is common after stroke and it is reported that over three quarters of stroke survivors report arm weakness, which can make it difficult for people to carry out daily living activities.

Functional Electrical Stimulation 

Functional Electrical Stimulation (FES) reactivates the nerves that are no longer controlled by the central nervous system. Bioness have developed the L300 Go and L100 Go lower leg FES devices. Unlike FES devices commonly supplied within the NHS which require a control box/pulse generator via long wires, or a heel switch, the L300 Go and L100 Go utilise wireless technology. The H200 wireless is also available as a upper limb solution.

The simple design makes it easy for users to don/doff, with the potential for single-handed application. The self-contained electric pulse generator (EPG) uses accelerometers and gyroscopes to provide 3D motion detection in all 3 kinematic planes and enables users to walk without the need for a heel switch, opening up freedom of choice for footwear and allowing the user to walk barefoot. The 3D motion detection and learning algorithm provides consistent stimulation, deployed in 0.01seconds and adapts to the users gait dynamics.

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Custom Made Orthoses

Our custom manufacturing unit at Ottobock Minworth specialise in hand crafted orthotics made to specification. The orthotist will design the orthosis depending on specific patient needs. Our experienced and award winning technicians ensure that each orthosis made is to the highest level of fit and comfort for your patient.

Ottobock Minworth blend cutting edge manufacturing techniques with traditional manufacturing skills to ensure the best possible outcomes for your orthotic device. A full range of AFOs, DAFOs, GRAFOs, and Stance control, Cosmetic and Convention KAFOs are available, complimented by Ottobock’s full range of world leading bars and joints.

Braces and Supports – Upper Extremity 

Limb weakness is common after stroke and it is reported that over three quarters of stroke survivors report arm weakness, which can make it difficult for people to carry out daily living activities.

The Omo Neurexa plus is a shoulder support that prevents or reduce subluxation, resists pathological movement patterns, has a forearm support to further offload the shoulder joint. The Clima Cool material also aids with sensory feedback.

The Omo Neurexa plus can also be used in conjunction with the Manu Neurexa plus, or the Manu Immobil Long – a wrist hand orthosis that stabilises and supports the wrist where the wrist or hand is paralysed. Together, these products make up the complete upper limb solution.

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Braces and Supports – Lower Extremity

Stock lower limb braces are designed to improve posture, mobility, walking speed and balance, as well as providing the end user with a greater sense of safety. 

The WalkOn Range are dynamic lower leg orthoses, suitable for indoor and outdoor use. The primary feature of the WalkOn orthoses is that they are dynamic – a particular benefit for patients with permanent dorsiflexor weakness. The range is made of glass fibre (Flex) and carbon fibre prepreg materials (Trimable, Reaction and ReactionPlus) which provide easy energy storage and return during the gait cycle. The ergonomic design of the WalkOn orthoses means they are discreet and inconspicuous to wear.

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Ottobock also offers a range of other lower limb braces for mild dorsiflexor weakness.

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Stance Control Orthoses (SCO)

Stance Control Orthoses, usually available through NHS funding, are for patients with partial paralysis or absent knee extensor power. In general they allow for free swing phase and stable stance phase. 

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If you would like to know more about any of these products please get in touch via orthoticsuk@ottobock.com or visit our website for more information: www.ottobock.co.uk.

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Therapies

‘Arts therapies can provide children with a voice’

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As Chroma partners with a North Devon school to deliver a full arts therapies service, Lucy Collings Pettit, a Neurologic Music Therapist with Chroma, discusses the power of such therapy in children

 

In September 2020, building upon successful existing music therapy provision, Pathfield School in North Devon introduced a full arts therapies service within their school, in partnership with Chroma. 

The Chroma team consists of a neurologic music therapist, an art therapist and a drama therapist. 

This is the first partnership where Chroma has been fully commissioned to provide a full arts therapies program within a single school.

Pathfield is a special school for children aged between three and 19 years of age with a range of complex needs. This includes pupils with autism spectrum conditions, learning disabilities, social, emotional and mental health needs, as well as neurological conditions including brain tumours, epilepsy, cerebral palsy and Hypoxic Ischemic Encephalopathy (HIE), whereby children were starved of oxygen at birth.

This year has seen the introduction of neurologic music therapy techniques (NMT) within the school. NMT is concerned with neuroplasticity, therefore the specific techniques used within the school setting are used to maintain or improve skills for those pupils with a neurologic condition – typically speech and language, motor and cognitive skills. 

The focus of NMT is to help these pupils acquire functional skills, usually for the first time. For pupils who suffered lack of oxygen at birth, they may have never known life any differently but, coming to terms with their condition is an important part of their rehabilitation. 

Rehab in this setting has a developmental focus – there are many barriers to learning to overcome and interventions are based on what will achieve the most functional and relevant educational outcomes.

There is huge potential for all three Chroma arts therapists to improve functional outcomes to those pupils who have neurological conditions and suffered a brain injury.  

Within this pupil population, the arts therapies as a whole are concerned with helping children come to terms with their condition. 

They may have difficulty communicating verbally or articulating their thoughts and feelings effectively, and arts therapists can help them to gain better insight into their conditions and express, explore and better manage their emotions – allowing them valuable opportunities to communicate and process their feelings and experiences. 

Arts therapies can provide children with a voice.

The fundamental role of the arts therapies in the school setting is to support pupils in achieving positive outcomes, including functional changes that ultimately enables children to overcome their significant challenges and barriers to learning.

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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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