JEN HASTINGS, MA, MT-BC

The Use of

Neurologic Music Therapy Techniques to Address Stroke

Purpose of Presentation

!! Stroke: presentation, what we can treat

!! MT techniques

!! Motor

!! Speech and Communication

!! Cognitive

!! Home training ideas

Neurologic Music Therapy (NMT)

!! Training out of CO State

!! Research-based methods grounded in neuroscience

!! Standardized techniques

!! This presentation is not an official NMT training

Quick and Dirty of Stroke

!! Lack of oxygen in brain due to blockage

!! Ischemic

!! Hemorrhagic

Time is Essential!

!! Can only get clot busters (rTPA) 3 hours post.

!! Learn signs and symptoms!

Quick and Dirty of Stroke

!! Results in

!!Motor issues, esp. hemiparesis

!!Sensory deficits

!!Communication/ speech deficits

!!Cognitive issues (decreased executive function & attention)

!!Emotional lability

!! Window of Recovery: 6 months post

Assessment, Goals

!!Use existing assessments and rehab tools.

!!What is priority?

!!Get patient buy-in.

!!Think generalization. How to measure?

Remember

!! Just because you’re past the Window of Recovery doesn’t mean you won’t see changes.

Motor

Motor

!! Physiological Entrainment:

!! When frequency of one system determines frequency of activity in another.

Internal oscillator (time keeper) entrains to a more powerful external

oscillator (metronome or music).

Motor Responses to Music –

(i.e. tapping your foot or fingers)

!! Audio-Spinal Facilitation !! Auditory stimuli excite neurons in the spinal cord which then

readies or primes muscles for movement at pre-cognitive level.

!! The more intense the stimulus, the greater the neuronal-muscular response.

!! Rhythmically structured sound patterns can entrain the timing of muscle activation patterns !! measured by EMG

!! facilitates more efficient movement (gait, hop, skip, etc.)

Entrainment

!! Entraining by tapping to a metronome has affects an

array of areas in brain, especially the basal ganglia,

cerebellum, and different cortical areas (Molinari et

al., 2003).

Rhythmic Auditory Stimulation: (RAS)

!!Gait training with rhythmic cue

!!Metronome

!!Music very strong downbeat

!!Use songs if patient can process; metronome only

if not.

!!Best songs?

Gait Cycle

Some Research on Stroke and Gait

!!After 3 trials, survivors of stroke showed

"!Improved weight bearing stance time on paretic side

"!Improved stride symmetry

!!Compared to conventional therapy, 6-week RAS

walking program significantly increased

"!gait speed

"!stride length weight-bearing time on the paretic leg !! Thaut, M. H.; McIntosh, G. C.; Rice, R. R. (1997). Rhythmic facilitation of gait training in hemiparetic stroke rehabilitation. Journal of Neurological Sciences,

(5), 207-212.

!! Thaut, M. H.; McIntosh, G. C.; Rice, R. R.. & Prassas, R. G. (1993). Effect of rhythmic cuing on temporal stride parameters and EMG patterns in hemiparetic gait of stroke patients. Journal of Neurologic Rehabilitation, 7, 9-16.

Assessment

!! 10 meter (feet) walking test

!! Look online for more tests- ex. Timed Get Up and Go !! http://web.missouri.edu/~proste/tool/

!! Look up expected stride length, speed and cadence for each age group; cite in report.

!! Reassess often.

In-Depth Gait Training

!! Spend time watching people walk

!! Difference between walking and running?

!! Rhythm: limping versus not limping?

!! Inadequate toe lift

!! Inadequate heel strike

Therapeutic Instrumental Music Performance (TIMP)

!! TIMP musical instruments used to exercise and simulate functional movement patterns.

!! Musical instruments and their appropriate spatial

configurations train !! range of motion, !! endurance, !! strength, !! adduction/abduction, !! supination/pronation, !! flexion/extension,

!! digit dexterity, !! limb coordination, etc.

TIMP: increased feedback for motor learning

Patterned Sensory Integration (PSE)

!! Rhythmic, melodic, harmonic, and dynamic elements of music structure mvt. cued through !! Temporal

!! Spatial

!! Force

!! Way to communicate nonverbally what you want your patient to do.

!! Example

Toe Off, Heel Lift

Typical goals for gait

!! Being able to ambulate ___ distance before fatigue

!! Cadence improved to ____ steps per min

!! Improved heel strike & toe clearance

!! Able to go up and down stairs

!! No loss of balance or falls for ___ time.

!! Thaut, M.H. (1999). Training Manual for Neurologic Music Therapy.

Speech and Communication

!! Where was the lesion?

!! Aphasia "!Broca’s Area= Expressive Aphasia

"!Patient understands fine but has issues talking (output)

"!http://www.youtube.com/watch?v=f2IiMEbMnPM&p=7FED96838230089E&playnext=1&index=74

Expressive Aphasia Techniques

!! If purely expressive: Melodic Intonation Therapy (MIT)*

!! Therapeutic Singing (TS) (breath support, expression, articulation- as well as calming, organization)

!! Musical Speech Stimulation (STIM): fill in the blank

!! See original Sparks research & Baker, F. (2000). Modifying the melodic intonation therapy program for adults with severe non-fluent aphasia, Music Therapy Perspectives, (18)2, 110-114.

Receptive Aphasia

!! Wernicke’s Area=Receptive Aphasia !! http://www.youtube.com/watch?v=dKTdMV6cOZw

!! Can talk but can’t understand

!! Mixed aphasia: both receptive and expressive

!! Very tough to treat!

!! Vocal Intonation Therapy: exercises to train the ear to hear sounds. Start with vowels, collaborate with SLP.

Apraxia

!! Disorder of motor planning

!! Rhythmic Speech Cueing !! Rhythmic

!! Patterned

!! Oral Motor and Respiratory Exercises (OMREX)

Cognitive Goals

!! Increase Attention !! Sustained

!! Divided

!! Alternating

!! Selective

!! Increase Executive Function

Home Training

!! To induce repetition!

!! Recordings for communication !! Audio- MIT, Vocal Intonation Therapy

!! Video singing/ saying words

!! If safe/ possible: RAS (gait training) !! With specific instructions!

!! Compliance: utilize their support system; fill out training sheet.

Questions

References

!! Albert, M., Sparks, R., & Helm, N. 1973. Melodic intonation therapy for aphasics. Archives of Neurology, 29, 130-131.

!! Belin, P., Van Eeckhout, P., Zilbovicius, M., Remy, P., Francois, C., Guillaume, S., Chain, F., Rancurel, G., & Sampson, Y. 1996. Recovery from nonfluent aphasia after melodic intonation therapy. Neurology, 47, 1504-1511.

!! Gregory, D. 2003. Music listening for maintaining attention of older adults with cognitive impairments. Journal of Music Therapy, 39 (4), 244-264.

!! Lamontagne, A. & Fung J. 2004. Faster is better: Implications for speed-intensive gait training after stroke. Stroke, 35 (11), 2543-8.

!! Luft, A.R., McCombe-Waller, S., Whitall, J., Forrester, L.W., Macko, R., Sorkin, J.D., Schulz, J.B., Goldberg, A.P., & Hanley, D.F. 2004.

Repetitive bilateral arm training and motor cortex activation in chronic stroke: A randomized controlled trial. JAMA, 292 (15), 1853-1861.

!! McCombe, W.S., Harris-Love, M., Liu, W., & Whitall, J. 2006. Temporal coordination of the arms during bilateral simultaneous and sequential movements in patients with chronic hemiparesis. Experimental Brain Research, 168(3), 450-4.

!! Patel, A.D., Iversen, J.R., Wassenaar, M. & Hagoort, P. 2008. Musical syntactic processing in agrammatic Broca’s aphasia. Aphasiology, 22, 776-789.

!! Patel, A.D. 2003. Rhythm in language and music: Parallels and differences. Annals of the New York Academy of Sciences, 999, 140-143.

References

!! Prassas, S.G., Thaut, M.H., McIntosh, G.C., & Rice, R.R. 1997. Effect of auditory rhythmic cuing on gait kinematic parameters in stroke patients. Gait and Posture, 6, 218-223.

!!

!! Schlaug, G., Marchina, S., & Norton, A. 2008. From singing to speaking: Why singing may lead to recovery of expressive language function in patients with Broca’s Aphasia. Music perception, 25, 315-323.

!! Schlaug, G., Marchina, S. & Norton, A. 2009. Evidence for plasticity in white-matter tracts of patients with chronic Broca’s aphasia undergoing intense intonation-based speech therapy. Annals of the New York Academy of Sciences. Annals of the New York Academy of Sciences. 1169, 385-394.

!! Straube, T., Schulz, A., Geipel, K., Mentzel H.J., & Miltner, W.H. 2008. Dissociation between singing and speaking in expressive aphasia: the role of song familiarity. Neuropsychologia, 46, 1505-1512.

!! Teasell, R.W., Bhogal, S.K., Foley, N.C., & Speechley, M.R. 2003. Gait retraining post stroke. Topics in Stroke Rehabilitation, 10 (2), 34-65.

!! Thaut, M.H., Kenyon, G.P., Hurt, C.P., McIntosh, G.C., & Hoemberg, V. 2002. Kinematic optimization of

spatiotemporal patterns in paretic arm training with stroke patients. Neuropsychologia, 40, 1073-1081.

References

!! Thaut, M.H., Kenyon, G.P., Schauer, M.L., & McIntosh, G.C. 1999. The connection between rhythmicity and brain function. IEEE Engineering in Medicine and Biology Magazine, 18 (2), 101-108.

!! Thaut, M.H., McIntosh, G.C., Prassas, S.G., & Rice, R.R. 1993. The effect of auditory rhythmic cuing on stride and EMG patterns in

hemiparetic gait of stroke patients. Journal of Neurologic Rehabilitation, 7, 9-16.

!! Thaut, M.H., McIntosh, G.C., & Rice, R.R. 1997. Rhythmic facilitation of gait training in hemiparetic stroke rehabilitation. Journal

of Neurological Sciences, 151, 207-212.

!! Thaut, M.H., McIntosh, G.C., Rice, R.R., & Prassas, S.G. 1993. The effect of auditory rhythmic cuing on stride and EMG patterns in

hemiparetic gait of stroke patients. Journal of Neurologic Rehabilitation, 7, 9-16.

!! Thaut, M.H., McIntosh, G.C., Rice, R.R., & Prassas, S.G. 1993. Effect of auditory rhythmic cuing on temporal stride parameters

and EMG patterns in hemiparetic gait of stroke patients. Journal of Neurologic Rehabilitation, 7, 9-16.

!! Thaut, M. H. 2003. Neural basis of rhythmic timing networks in the brain. Annals of the New York Academy of Sciences, 999, 364-373.

!! Thaut, M. H. 2005. Rhythm, music and the brain: Scientific foundations and clinical applications. Routledge: New York. !! Whitall, J., McCombe, Waller, S., Silver, K.H., & Macko, R.F. 2000. Repetitive bilateral arm training with rhythmic auditory

cueing improves motor function in chronic hemiparetic stroke. Stroke, 31 (10), 2390-2395.

!! Yoo, J. 2009. The role of therapeutic instrumental music performance in hemiparetic arm rehabilitation. Music Therapy

Perspectives, 27(1), 16-24.