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.”
What’s a Duchess without a G&T darling?”
Laura Nicholls, lead speech and language therapist at The Bridge Neurological Care Centre in Middlesbrough, reflects on the rehabilitative journey of her patient Angela on regaining some normality following a lengthy admission in intensive care.
Firstly there’s a couple of things you need to know about Angela before I can tell you about her journey. She isn’t usually one to let another person speak for her but I have been given full permission to share with you all the ups and downs of her rehabilitative journey.
Angela has acquired the very fitting nickname ‘The Duchess’. This comes from her previous occupation as a community matron, her fine eye for detail, her drive for perfection and her tendency towards bossiness.
In April 2019 Angela was admitted to hospital with Myasthenia Gravis that resulted in Myasthenic crisis (respiratory failure).
Myasthenia Gravis is
a rare long-term neurological condition that causes muscle weakness.
In Angela’s case she experienced severe difficulty swallowing, loss of voice (aphonia) and severe breathing problems.
This resulted in the insertion of a tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe/ trachea to help you breathe) with 24/7 ventilation to assist with breathing.
This emergency procedure can often cause weakness and structural damage that further complicates an individual’s recovery of function. This means that often the long-lasting impact of having difficulty speaking, eating and drinking on someone’s quality of life is not fully realised until the months after initial survival has been achieved.
It is the role of a speech and language therapist to provide assessment, treatment and support for individuals who have difficulties with communication, or with eating drinking and swallowing.
Angela’s swallow and voice were severely affected second to muscle weakness and poor breath support. This resulted in poor airway protection when she was eating and drinking meaning food and fluids entered the trachea and lungs rather than the oesophagus leading to the stomach. This can cause serious health concerns as it can result in airway obstruction (choking), chest infections, pneumonia and death.
I worked closely with Angela to identify what was most important to her and what would make a difference to her quality of life and wellbeing. Angela identified that she would love to be able to have a gin and tonic and FaceTime her family and friends without them having difficulty hearing her.
This was a huge target for a lady who was nil by mouth with an unsafe swallow having all her nutrition and hydration needs met via a tube into her stomach (percutaneous tube) and who had a very weak voice; Angela’s friends and family would often ring her but could only have a one-sided conversation as Angela’s voice was too weak to be heard over the phone.
From thorough assessment, I created an intensive swallow and voice rehabilitation programme when Angela was discharged to us in August 2019 which utilised specific muscle building/strengthening exercises to target the areas of breakdown in her voice and swallow.
This programme focused on improving oral control and coordination, improving laryngeal elevation and hyoid excursion (good range of movement is required to swallow safely), improve airway protection, increase strength of cough and strengthen her vocal cords to increase strength of voice. Angela completed this programme multiple times per day.
Her exercises were recorded onto her iPad for her to work through daily and support her in the completion of these.
Angela’s recovery and ability to wean from ventilation was lengthy and unpredictable at times. She suffered a number of setbacks and respiratory complications during her recovery that impacted her ability to complete therapy. However she remained determined and focused on what she wanted to achieve.
By December 2019, she made significant progress. Through her dedication and perseverance with her rehabilitation programme she achieved her goals. After months of being unable to eat and drink Angela’s swallow was now safe – she was able to eat and drink without difficulty or fear of choking.
Angela’s voice was also a lot stronger, she went from being inaudible on the telephone to being intelligible 100 per cent of the time and being understood in all communication environments with no incidents of communication breakdown with familiar or unfamiliar listeners.
Angela continued with her rehabilitation programme and in February 2020 she attended her local flower club meeting where she addressed all 70 attendees, delivering a 10 minute speech without difficulty.
This was a major achievement given that she was struggling to make herself heard to one individual in a quiet room six months prior.
It was a moment of great pride when she introduced me to the audience saying: “This is Laura, my speech therapist, without whom I would not be able to speak to you all today and without whom I would not be able to enjoy this gorgeous spread you have put on for us all.”
In March 2020 the tube into Angela’s stomach was removed as she no longer needed it to meet her nutrition and hydration needs – she could do this by eating and drinking herself.
The therapy outcome measures graphs clearly show the positive outcomes she has been able to achieve through therapy, but the true outcome is written all over her face – smiling ear to ear.
Through therapy Angela did not just regain the ability to speak and swallow, she gained confidence in recovering functions that she thought she had lost forever and a new appreciation for the things in life that people often take for granted.
Angela has been a complete joy to work with and one of the greatest honours of my career has been to work alongside her.
Now enjoy your G&T Duchess – you deserve it.
Laura Nicholls is a speech and language therapist at The Bridge Neurological Care Centre in Middlesbrough, which provides specialist inpatient neurological rehabilitation and complex care for people with neurological illnesses, acquired brain and spinal cord injuries. For more info visit www.elysiumhealthcare.co.uk.
Music in the key of R
Rehabilitation journeys are increasingly being guided by the rhythmic interventions of music therapists but challenges in opening up access remain; as Chroma’s Daniel Thomas explains.
Daniel Thomas, managing director of art therapies provider Chroma, developed an interest in music at a young age. However, he’s concerned that young people today aren’t exposed to enough music education, and that this will have a knock- on effect on music therapy, which can help a range of people, including those with a brain injury.
“There have been massive cutbacks, a killing off of music in schools,” Thomas says, “Which has had a huge effect over many years as that side of school life has been systematically eked away and cut back.
“If people aren’t exposed or brought into music education early in their lives, it probably won’t happen later on in a way that’ll lead to them considering music therapy as a profession.”
“I’d be delighted if Boris Johnson and the education secretary saw the significant social value and healthcare value of having music in the education curriculum. It’s almost criminal to strip it out in the way it has been stripped out by Labour and Conservatives, and it needs to go back in as matter of national urgency.”
Chroma is a trailblazer for the government’s new arts therapy apprenticeship scheme, however, which is giving Thomas hope that more people will enter the profession in the future.
“I’m hoping a much more diverse range of candidates applying to be arts therapists will come in, but it will take ten years to see the results of that.”
There’s also a need for the NHS to spend more money on arts therapy, which also includes drama and art, he argues.
“The NHS used to be the biggest employer of arts therapy, but with various cutbacks, those jobs have gone.
“I think there are huge untapped resources within arts therapy professions, but that takes significant amounts of education.”
Thomas, however, generally feels very positive about the strides music therapy has taken in recent years.
There is a growing recognition of the power of arts therapies, he says, and in recent years, a growing body of research on how music therapy can help many groups of people with many injuries and conditions.
The Covid-19 pandemic has forced professionals in arts therapy, including the roughly 70 therapists who work for Chroma, to work together, and
“Covid has spurred on the profession and ourselves to open up our minds to other ways of working, while at the same time, holding onto core clinical ethics as therapists: are we doing no harm, and are we supporting that person to work towards the goals they feel are important?”
This could have cost benefits.
Conversations around this are easier today, because the profession is only now starting to talk more openly about the financial side of their work.
“For years, the economics side of the profession, how much you charge, was a bit taboo, therapists felt uncomfortable thinking about the financial aspect of what we do,” Thomas says.
“But the profession is catching up to itself around this, and learning from other sectors.”
Music therapy, as well as art and drama therapy, are regulated by the Health and Care Professions Council, and arts therapists are allied health professionals (AHPs), which means they’re on the same level as speech therapists, physiotherapists and many more.
Music therapists, including Chroma therapists, work within the NHS, and in private clinical practices.
Thomas says music therapists work as key components in multi-disciplinary teams (MDTs) helping the recovering of patients with brain injury. “We’re very collaborative – we want to follow MDT goals.
Because music stimulates a diverse range of brain areas and networks, it has an impact on speech and language, on the sensory motor system, cognitive function and the emotional wellbeing of the client.”
“Music therapy connects across a hugely diverse range of areas in the brain and there’s research from neuroscience around the way in which when the brain is stimulated by music new neural pathways are created.”
“It’s not necessarily fixing the part of the brain damaged in an accident, but going round those areas and reconnecting parts of the brain, that’s why people should feel really confidence in using music therapy and using music therapists as highly skilled professionals.”
Music therapy contributes to the expertise of numerous disciplines, Thomas says. Some patients will prefer to work towards their goals when music is the context through which that treatment is delivered, and there are many ways music can be used in their therapy.
For example, for a client who has issues walking, the rhythm of a song could be used to help them walk, or using the melody of a song to enable a sequence of steps to carry out a particular task, such as making a cup of tea.
A patient’s engagement with therapy can be improved by playing music they know – which is why, Thomas says, music therapy can be bespoke and person-centred.
A familiar song can be used by therapists, for example, to help connect a patient with their life before their brain injury and who they are now, bridging the gap between the two.
Slow music can also be used to help control anxiety by slowing down the heart rate. When a client shows signs of calming down to a particular piece of music, the therapist can share this with the MDT so it can be applied across the patient’s care.
“If their heartrate and breathing goes through the roof during personal care episodes, we can help work with the staff team to say that, from music therapy sessions, we can see that the client’s breathing slows and their heart rate reduces with this particular music.”
In this case, the piece of music could be played before and during personal care so that it can be reframed within the context of the music. Overall, Thomas is hopeful for the future of music therapists; for the apprenticeship scheme that will hopefully boost awareness of the profession, and for the research that continues to bolster
“It’s an interesting time to be in the arts therapies, and a great time to be a music therapist.”
The relationship between music and running
By Daniel Thomas, joint managing director of Chroma Therapies.
By Daniel Thomas, joint managing director of Chroma Therapies
With its ability to produce new neural pathways, Neurologic Music Therapy is able to encourage movement, co-ordination, improve speech and language, and improve the ability to read/feel emotions, reactions and more, in people living with catastrophic injuries.
This is because music automatically connects to the brain. And this automaticity is what makes music so powerful.
Music also has to ability to push your training capabilities farther and faster especially in running.
This is why a running playlist is the ideal accompaniment to any runner.
Each songs tempo stimulates the brain, evoking a running response of either a faster pace or a steady rhythm depending on what you want to achieve.
For a faster pace, a good running playlist should contain songs with 150-180bpm.
Unfortunately, with not many songs out there using that speed (unless you enjoy rock, metal or speed garage for running) than the other option is to choose songs with 75-90bpm, as this tempo is perfect for a steady rhythm and maximising efficiency.
Do you recall an earlier blog where we discussed cadence and stride length using NMT for preventing falls in the elderly?
We suggested music with a high bpm count promotes movement, good cadence and walking speed, so songs like Nancy Sinatra’s ‘These Boots are Made for Walkin’, which has 85 bpm, is ideal.
BPM strongly correlates to step cadence.
Rhythmic Auditory Stimulation (RAS) is an important aspect of NMT.
Predictable rhythmic structure allows the sensori-motor system to move in sync with the beat.
This is, in essence, why music is important to runners, as it has the ability to communicate with the brain in order to help maintain a steady pace or increase speed depending on the bpm.
When it comes to mental wellbeing, we will always discuss music’s ability to improve mental wellbeing, and its effect can also be attributed to runners.
Music’s ability to improve stride, cadence and style, to produce better and better runs, and enable runners to achieve personal goals also have a positive effect upon mental wellbeing.
A sense of accomplishment. And with the right playlist, runners can end each run on a high.
We also like to discuss how NMT is more effective when it is personalised to that individual.
The same can be said in the case of a runner. A playlist that includes, not only songs with the ideal tempo for them, but also have some personal meaning, have the greatest positive effect upon runners.
The more enjoyable the run, the less fatigue is experienced. This may be due to the fact that music is able to interfere with the parts of the brain that communicate fatigue, essentially causing a distraction, so less fatigue is experienced.
For runners, the relationship between music and running can be seen to be just as effective and important as the relationship between music and recovering from a brain injury.
Its ability to improve running capability, speed, motivation, and promote mental wellbeing is what makes the difference between a run just being a run and reaching ‘Flow State’ – the mental state where the runner is in the moment of running – no distractions, and the run becomes…euphoric.
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