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.”