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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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Management during a pandemic: what we’ve learned

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As the country faces the second wave of the coronavirus pandemic, the management team at Richardson Care reflect on their experiences so far. Richardson Care has six specialist residential care homes – three for adults with acquired brain injury and three for adults with learning disabilities. Caring for up to 78 people, many of whom are vulnerable brings added responsibilities and pressures, as well as additional skills.

Our experience in supporting people who are rebuilding their lives after brain injury or living with learning disabilities means that we are problem solvers. We support people to overcome challenges every day. Never has this been more important and we’re proud of the way that our management team and staff have responded.

We asked our Homes Managers for their personal views and experiences of the pandemic – from their initial reactions to plans for the future. We discover what we’ve learnt, and how we can change things for the better.

Resilience
‘The capacity to recover quickly from difficulties; toughness’ has been demonstrated by our team throughout the pandemic. Jane Payne, Operational & Clinical Officer at Richardson Care, takes us back to the beginning of the year: “On February 18th 2020 we informed staff that there was a new virus, and preventative measures were put into place; including hourly touch point cleaning, increase in hand washing and an increase in awareness. Ahead of government guidance on March 12th 2020, we took the very tough, necessary decision to close our doors to family and friends to protect service users. We made sure that all staff worked only in one home, so in the event of an infection, it would not be transferred from one home to another by our staff.”

“The management team have become incredibly solid; working as one in supporting each other, as and when each has needed, as we live and work through the rollercoaster that is Covid-19. I am proud to lead; and be part of such a strong group of individuals displaying a sole purpose of ensuring the care, welfare, safety and security of our service users and staff. Richardson Care has shown we are more than resilient, we have become stronger through experience. Care: it’s in our DNA.”

Jacky Johnson, Registered Manager at our Boughton Green Road home for adults with acquired brain injury talks about the realities of dealing with something that no one had ever experienced before. She says: “We were dealing with real disease: a real virus, in real time with real people…The guidance received from various governing and public bodies changed before the ink could dry…The initial fear demonstrated by some staff left others having to broaden their shoulders… taking on extra activities within their daily routines…The expectation on myself as a Manager weighed heavily, it felt like I should know all the answers to the questions they asked… I was clear of my expectations from my team and them of me… Resilience: it’s not about how many times you fall… it’s about how many times you stand up and face another day.”

Teamwork
It was important to create a positive spirit as we knew our response would impact our service users. Central staff were redeployed so each home had enough admin and maintenance support in their team. This means they have been able to form closer relationships with the service users, some have been helping out with maintenance jobs – developing their skills and feeling valued while completing meaningful activities.

The teams within each home became closer, bonding more as they faced challenges together. No job was too big.

Weekly management meetings moved online in February. The Managers have worked more closely together while being socially distanced. Helen Petrie, Manager at The Richardson Mews adds: “No-one has ever been in this position before. We’re all learning together and supporting each other. We’re there to boost morale when it’s needed, sharing experiences and insight to keep our service users and staff happy and safe.”

Resourceful
We’ve found more efficient ways of operating – reducing risk while continuing to help our service users develop their daily living skills. For example, instead of going out to the shops several times a day, there’s just one trip per day. This means planning ahead, so service users have been helping to plan the menus, write shopping lists and prepare for their daily needs. These all require cognitive skills.

We have all become much more tech-savvy, using the internet, apps, photos and video calls as well as phone calls and letters to keep in touch with service users’ family and friends. We’ve also been checking in with each other more too.

Wendy Coleman, Registered Manager at our Duston Road home adds: “For service users, routine is a major part of their life. When their usual activities are no longer possible – no home visits, day services, community activities – staff have shown how well they have supported service users, reassuring them throughout all this. They have also been dealing with more challenging behaviours due to service users’ complex needs and lack of understanding of what is happening. We have created different routines and activities, promoting health and exercise.”

At The Richardson Mews (inspired by Joe Wicks) the day now starts with ‘Morning Motivation’ – exercising to music every day to improve fitness, flexibility and well-being. We’re also making more use of our in-house gym equipment. One service user who has a brain injury thrived during lockdown: he was in a wheelchair in February and now he can walk 70 lengths of the parallel bars.

Although the service users have missed going out, we have had plenty of scope and opportunity to develop in-house activities. Our large gardens and outdoor spaces have been used for gardening, ‘coffee shops’, sports and games, trampolining and treasure hunts. Our indoor communal spaces have hosted quizzes, craft activities, music and karaoke sessions. We’ve celebrated birthdays with gifts, parties and barbecues. We’ve maintained structure when needed, providing mental stimulation, social interaction and fun, while supporting well-being and skills development.

Appreciating each other
“The new normal is valuing and appreciating the simple things in life and each other, focusing on the positives,” adds Wendy Coleman. As we have gone through the months, we’ve noticed positive changes in service users – improved bonding with staff due to them having much more 1-1 time. Individual service user’s communication skills have also improved.

“Staff have done all this whilst dealing with the impact on their own lives. I feel through all this we all have changed our priorities, we have learnt different coping skills, adapted to change, and have gained new skills.

“It is important to show how we value, support and appreciate each other, talk more, respect and most importantly listen to each other. Learning that showing praise and valuing people is so important in these difficult times.”

Never has the responsibility of managing specialist care services been so great. As we prepare for the next phase of the Coronavirus pandemic, we know that we have the experience, skills and resilience to face the challenges ahead.

Richardson Care provides specialist residential care and rehabilitation for adults with acquired brain injury and learning disabilities. An independent family business with a 30-year track record, it has six residential care homes in Northampton. Find out more at www.richardsoncares.co.uk

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Case manager shares lockdown experiences in Q&A

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Case management has faced many challenges during the COVID-19 pandemic, to enable vital support continues to be delivered to clients. Here, in the first in a series of Q&A features with case managers across the country, Lisa Brown, managing director of Coastal Case Management, shares her experiences 

How did you adapt to the restrictions of lockdown? Were you able to do this quickly or did it take a bit of time?

We were pretty much set up with remote working and had literally just got our own IT man, who was invaluable. We changed to Sharepoint so the new way of working was certainly a challenge. It took a few weeks for us to settle in to our new world of Zoom and Microsoft Team chats but I love it. 

What have been the main challenges – were you able to overcome them? 

It was hard for our clients, especially those with visual impairments. We set up Alexa with the voice assist for our blind patient. We set up Drop In an it was quite a shock when suddenly he would drop in! Lessons learned there for sure. 

Has the use of telerehab been of benefit to you? 

Massively, we have reduced travel costs and time significantly. It’s been good for the environment, as well as my back!

How have your clients responded? Was it difficult for them to adapt to? 

For some they have embraced tech, for others they have not been able to engage. We were able to assess those needing face-to-face interaction, and fortunately this was allowed if medical grounds required. 

Do you feel the lack of face-to-face contact with clients or/and colleagues has been damaging?

It’s hard to know the outcomes from this. I think all of our virtual INAs went really well. We were able to break down the questions and do them over several days, perhaps an hour at a time, rather than cramming it all into a visit. There are undoubtedly winners and losers. Brain injured clients and the elderly in care homes have suffered the most from lack of physical visits.

How central do you think the use of telerehab will be for you going forward?

100% we will consider this as a first step, although there are many therapies that require hands-on and a visit. You miss so many subtle things over Teams or Zoom. In the main we feel they will be very effective for monitoring and progressing treatments. 

How do you think the future of case management has been shaped by the pandemic? 

Our face-to-face visits will reduce significantly, so this will reduce time costs of travel and fuel. This benefits the whole medico legal system. I would love to have more MDT meetings virtually, again a massive cost saving and more people turn up. It also means less time out of clinics for many professionals. Hospital staff loved it, so for me it’s been a massive game changer.

Will you be doing anything differently within your business going forward compared to pre-pandemic? 

Use of Teams and Zoom will continue, and MDT meetings will all be virtual if I have my way. We will have a more flexible working policy. Staff have in the main worked well from home, although we will keep our offices for some meetings. It is important to have human touch …

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First non-human primate study showing promise of gene therapy for stroke repair

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Stroke is a leading cause of death and severe long-term disability with limited treatment available. A research team led by Prof. Gong Chen at Jinan University, Guangzhou, China recently reported the first non-human primate study demonstrating successful in vivo neural regeneration from brain internal glial cells for stroke repair.

Ms. Long-Jiao Ge, the first author of the work and a PhD student in the Institute of Zoology, Chinese Academy of Sciences, said: “Current treatment of ischemic stroke mainly aims at restoring blood flow and neuroprotection, typically with a narrow time window of several hours.

“However, many stroke patients cannot reach hospital within a few hours after the onset of stroke, and may suffer from a large number of neuronal death and loss of brain functions. Therefore, how to regenerate functional new neurons after stroke is the key to restore brain functions.

“We have previously published a series of works demonstrating that overexpression of a single neural transcriptional factor NeuroD1 can directly convert glial cells into neurons in mouse brains. However, most clinical trials on stroke have failed in the past decades, suggesting that successful rodent studies may not be sufficient for clinical translation. Because in vivo glia-to-neuron conversion is such an innovative technology, we decided to take an important step to further validate this new technology in non-human primates”, Prof. Chen explained the original intention of this work.

In this study, Prof. Chen and his team first established an ischemic stroke model in rhesus macaque monkeys aged from 9 to 21 years old to capture the typical occurrence of stroke among senior population of humans. Using astrocyte promoter GFAP to control the expression of neural transcriptional factor NeuroD1, Chen’s team demonstrates successfully that reactive astrocytes caused by ischemic stroke in the monkey brain can be efficiently converted into neurons. “We are very happy to see that the neuronal density in NeuroD1-treated areas is consistently higher than that not treated with NeuroD1”, said Ge proudly.

“An unexpected finding is that a class of interneurons, that are sensitive to stroke injury, are significantly protected after NeuroD1 treatment, accompanied by a significant reduction of neuroinflammation. This result has important implication that in vivo astrocyte-to-neuron conversion not only regenerates new neurons but also protects the injured neurons from secondary damage, preventing further neuronal loss. Such findings of combinatorial effects of neuroregeneration plus neuroprotection may have profound impact on brain repair”, said Prof. Chen.

“What we have developed here is a unique gene therapy, using adeno-associated virus (AAV) vectors to deliver transgene NeuroD1 through direct intracranial injection into the ischemic region in primate brains. Different from classical gene therapies aiming for correction of gene mutations, our gene therapy regenerates new neurons, making it a kind of gene therapy-mediated cell therapy. We call it neuroregenerative gene therapy”, Prof. Chen commented on this innovative new technology.

“This study in non-human primates opens a new avenue using neuroregenerative gene therapy to repair damaged brains, which brings new hope to millions of patients suffering from stroke and other neurological disorders,” concluded Prof. Chen.

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